HospitalInspections.org

Based on document review and staff interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of photographs of wounds/pressure ulcers as they change and/or at least 48 hours prior to discharge for 1 of 8 (#1) closed patient medical records reviewed.

Findings:

1. Policy #H-WC 02-001 PRO, Wound Assessment, revised/reapproved 2/2014, indicated on pg. 2, point 5., "Wound photos will be obtained on admission for all pressure ulcers, diabetic wounds, venous ulcers, arterial wounds, surgical wounds, or other complex/atypical wounds...Photographs should be re-done at a minimum as the wound(s) change(s), monthly, and within 48 hours prior to discharge."

2. Review of closed and open patient medical records, confirmed:
A. patient #1 was admitted 7/21/15 at 1810 hours for nutritional impairment and diarrhea and:
a. skin assessment on 7/22/15 indicated photographs were taken of: stage III coccyx pressure ulcer, surgical wound of abdomen, left and right lower extremities, top of right and left hands skin tears, and left heel.
b. a photograph was taken again on 8/3/15 of only the unstageable coccyx pressure ulcer.
c. lacked photographs of the other wounds that were identified on 7/22/15 as the wound(s) changed and at least 48 hours prior to discharge.
d. Patient was transferred in stable condition via ambulance on 8/3/15 to F2 for surgical intervention of ischemic bowel due to Short Bowel Syndrome.

3. Staff P4 (Registered Nurse, Certified Wound Care Associate) was interviewed on 8/28/15 at approximately ¿¿1359 hours, and confirmed all wounds were photographed on admission, but not photographed as the wound(s) changed and at least 48 hours prior to discharge as required by facility policy and procedure.