HospitalInspections.org

Based on document review and interview, the nursing supervisor failed to ensure that the wound care policy was implemented for 4 of 7 patients whose closed medical records were reviewed (Patients #1, #2, #3, and #7).

Findings:
1. Review of the policy "Wound Assessment", policy number H-WC 02-001 PRO, original date 02/2014, indicated under "Procedure", on page 2, in item 5., "Wound photos will be obtained on admission for all pressure ulcers, diabetic wounds, venous ulcers...surgical wounds or other complex/atypical wounds...Photos may be obtained by the admitting nurse as part of the admission assessment or within 24 hours of admission...photos may be taken by staff RN (registered nurse), LVN (licensed vocational nurse), WCC (wound nurse), or Nursing Supervisor competencied in wound photography. 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 medical records indicated:
a. Pt. # 1 was discharged on 8/17/15 and had only admission photos taken on 7/31/15.
b. Pt. #2 was discharged on 8/7/15 and the last photos taken were on 7/29/15.
c. Pt. #3 was discharged on 8/5/15 with the last photos dated 7/15/15, the day after admission.
d. Pt. #7 had photos on 7/28/15, the day after admission, and none further with the patient's death occurring on 8/4/15.

3. At 8:15 AM and 12:00 PM on 9/15/15, interview with the wound care coordinator, staff member N2, indicated:
a. It was unknown that pt. #1 was being discharged on Monday, 8/17/15.
b. Per Social Services notes on 8/14/15, surgery was scheduled for 8/17/15.
c. Per staffing schedules, wound care staff were on site for 6 hours on 8/14/15 and could have taken photos of the wound(s) for pt. #1 prior to discharge.
d. Pt. #2 went to the hospital for a test and did not return, thus no discharge photo(s) were taken as discharge was unexpected.
e. There was no documentation in the medical record that indicated pt. #2 was unexpectedly discharged and no discharge photos could be taken.
f. No other staff are competencied to take wound photos, and other staff do not have access to the camera used for photographing patient wounds.
g. At this time, the facility staff are not complying with the policy listed in 1., above, in regard to photographing patient wounds within 48 hours of discharge.