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Based on review of documents and staff interview, it was determined the Registered Nurses failed to supervise and evaluate the nursing care of a patient with a pressure wound in accordance with hospital policy relative to documentation by photography. This deficient practice affected one (1) of one (1) patient reviewed who had a decubitus ulcer noted upon admission (patient #1). This has the potential to adversely affect the quality of nursing care provided to all patients who have a wound at the time of admission or who develop a wound after admission. Findings include:

Review of hospital policy "Pressure Ulcers" revealed the policy was last reviewed 9/07. The policy states "Photographs will be taken of all skin breakdowns on admission. Repeated photographs will be taken each Friday betwen the hours of 7a - 7p for the above mentioned. This photograph will be taken by the nursing staff...Photographs will also be taken upon transfer to another unit or facility and upon discharge."

Review of the medical record for patient #1 revealed the patient was admitted to the 3 West nursing unit on 8/23/10 at 0059. The admitting Registered Nurse (RN) documented on the initial nursing assessment the patient had a stage II decubitus ulcer on the right heel. The nurse failed to take a photograph of the wound. The patient was transferred to the Critical Care Unit (CCU) on 8/23/10 at 0530. The RN in the CCU documented on 8/23/10 at 0530 "Decubitus noted pictured and placed on chart." The patient was transferred to the 4 South nursing unit on 8/24/10 at 1550. The RN on 4 South failed to take a photograph at the time of the transfer. There were no photographs taken on Friday, 8/27/10. The patient was discharged to a personal care home on 8/29/10 at 1723. There were no photographs taken prior to the discharge.

Review of the medical record revealed there were no photographs documented. The Director of Health Information Management and the Nurse Manager of CCU and 4 South were interviewed in the afternoon on 9/21/10. They confirmed there were no photographs documented on the record. The Nurse Manager stated the nurse who documented that she had taken the photograph in the CCU informed her that she took the photograph, but then failed to print it and place it on the medical record.

Based on review of documents and staff interview, it was determined there was no nursing care plan developed relative to skin care for a patient with a pressure ulcer and who was identified as being at moderate risk for further skin breakdown. This deficient practice affected one (1) of one (1) record reviewed of a patient who had a pressure wound at the time of admission. This has the potential to adversely affect the quality of nursing care provided to all patients who have a wound at the time of admission or who develop a wound after admission. Findings include:

Review of the medical record for patient #1 revealed the patient was admitted on 8/23/10 and was discharged on 8/29/10. The admitting Registered Nurse (RN) documented on the initial nursing assessment the patient had a stage II decubitus ulcer on the right heel. The nurse also documented the patient was assessed as being at "moderate risk" for developing further skin breakdown. There was no care plan developed at any time during the admission relative to care of the existing wound or prevention of skin breakdown.

The Nurse Manager of the 4 South nursing unit was interviewed in the afternoon on 9/21/10. She concurred with the findings on the medical record.