HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure the registered nurse supervised and evaluated the nursing care for each patient related to wound assessment for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy titled, "Standards of Care", was reviewed on 7/19/10 at 1:00 PM, and indicated on pg. 3, under Standard III Patient Care: AM Care section, bulleted points, "Skin and back side as well as other pressure points, i.e., heel, elbows, underarms, will be inspected BID (AM and HS care) and treated appropriately."

2. Policy titled, "Pressure Sores Risk Assessment", was reviewed on 7/19/10 at 1:00 PM, and indicated on pg. 1, under Policy section, "Visual skin inspection will be performed as part of assessments...All patients are assessed for risk of pressure sore formation or presence of existing pressure sores by performing a Braden Scale Score and Visual Inspection on admission and...daily...Existing pressure sores are reassessed by visual inspection at time of dressing changes or a minimum of every 72 hours. Document: Thorough visual inspection of the patient's skin on admission and visual daily skin assessment. All interventions performed."

3. Policy titled, "Care of the Patient with Skin Tears", indicated on pg. 1, under Policy section, "When a skin tear is noted (during assessment), document in the Medical Record. Include location, appearance, numbers and treatment initiated."

4. Incident Reports for March, 2010 through July, 2010 were reviewed on 7/19/10 at 12:20 PM, one found related to complaint indicated, on 4/2/10 at 8:00 AM, a 18 cm x 6 cm skin tear was noted, location and appearance were not documented.

5. Review of closed patient medical records on 7/19/10 at 12:12 PM indicated Patient N1 (client named in complaint) was a 78-year-old admitted to the facility on 3/24/10 at 16:10 PM for chief complaint of "continuation of medical management, strengthening for deconditioning and management of malnutrition and history of squamous cell cancer of the lung." Other documentation in the medical record included:

A. per Wound Assessment Photograph dated 3/30/10 at 3:29 PM, a wound was documented as "back and spine with stage II, Duoderm in place."

B. per Discharge Summary dictated 4/9/10, "During the hospital course, the patient developed some decubitus ulcer on the upper back..."

C. lacked documentation of an initial wound assessment and lacked documentation of measurement of back and spine wound during length of stay from 3/24/10 at 16:10 PM through 4/3/10 at 00:06 AM.

6. Personnel P7 was interviewed on 7/19/10 at 1:36 PM and confirmed all patients are to be assessed on admission for possible skin breakdown risk and/or wounds present and documented in the patient's medical record. The skin breakdown risk was assessed using the Braden Scale Score per facility policy and procedure. The documentation of wounds is to include the location, staging, measurements, and descriptions of tunneling/undermining, and other pertinent information. There was no documentation of an initial wound assessment and when the wound on the patient's back and spine was photographed on 3/30/10, there was no documentation of measurement of the wound. It was also not measured again during patient's length of stay, as required per facility policy and procedure.