HospitalInspections.org

Intakes: TN00043383

Based on policy review, medical record review and interview, the facility failed to follow policy for wound plan of care for 1 of 2 (Patient #3) sample patients with pressure ulcers on admission to the facility.

The findings included:

Review of the facility policy, "Wound Care Initial Plan of Care", revealed, " ...1. Patients admitted with existing wounds will be identified, and the patient and/or family member will be provided with the pamphlet "Wound Care Initial Plan of Care." 2. The patient and/or family will be contacted by a representative of the Hospital to set up a meeting within in a week of the admission. 3. The meeting will include the DON, CNO, DQM or Wound Care Nurse, and will include a review of the pamphlet, a short discussion of the status of their wound when the patient arrives (including sharing photographs if they are agreeable to see the wound at the time of admission, and the plan for their wound care during their stay ... 5. The patient and/or family member will be asked to acknowledge that the meeting has taken place by signing the Wound Care Initial Plan of Care Acknowledgement form ..."

Medical record review for Patient #3 revealed there was no documentation of a signed acknowledgement of Wound Care Initial Plan of Care.

During an interview in the Storage Room on 2/6/18 at 10:40 AM, the Interim Chief Nursing Officer (CNO) stated, "I don't believe there is an "Acknowledgement of Wound Status and Plan of Care information" on the chart. I spoke with the wound care nurse last night and this was done by a prior wound care nurse. "On 2/6/18 at 11:00 AM, the CNO verified there was no Acknowledgment of Wound Care Initial Plan of Care on the patients record.