HospitalInspections.org

Based on document review and interview, the facility failed to accurately document wound care in the medical record for 1 of 10 patients (patient #1).

Findings include:

1. Review of policy HD WC 01-001, last revised 02/28/14, Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds, indicated under Treatment Components:
10. Documentation to include:
a. The level of tissue destruction.
1) NPUAP (National Pressure Ulcer Advisory Panel) staging classification for Pressure Ulcers.
2) Partial thickness or full thickness tissue loss for non-pressure related wounds.
b. Wound characteristics to include tissue type, exudate amount/type, undermining /tunneling, surrounding tissue appearance, odor intially and with each dressing change.
c. Pain related to wound, dressing, and/or dressing procedure.
d. Communication with patient/family, staff MD or other licensed providers.

2. Review of patient #1 MR indicated the following:
He/she was admitted on 9/4/14. An order was written on 9/5/14 for wound care consult and treat. The medical record lacked evidence that the patient's wound dressing was changed after 9/6/14 (9/9/14, Tuesday and 9/11/14, Thursday).

3. The Wound Care Team Log indicated the dressing change was to occur every Tuesday, Thursday and Saturday.

4. Staff member #1 verified the medical record information in interview beginning at 3:00 p.m. on 2/20/15. He/she also indicated that the wound care logs were not part of a medical record.