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Based on review of the medical record, policy and procedure, and staff interviews, it was determined that the facility failed to supervise care and provide evidence of consistent wound assessment/wound care for 1 of 3 (#3) sampled patient records.

Findings were:

A review of facility policy entitled "Skin Care Algorithm", last reviewed 12/08/2010, revealed on admission, the patient was to be assessed from head to toe and documented in the medical record within eight (8) hours of admission. If a wound or altered skin integrity was present on admission or if there was a dressing in place, the dressing was to be removed and the area assessed as to the size, color, odor, and drainage. The physician was to be notified to obtain initial wound care orders. The policy indicated that skin reassessments were to be completed and documented every twelve (12) hours.

A review of the medical record for patient #3 revealed that the patient was transferred to the facility from a local hospital within the network. The transfer summary and care plan received by the facility indicated that the patient had right hip skin grafts and a left hip tissue injury.

A review of the physician orders revealed that on the fourth day after admission, an order was written for Santyl ointment (used for wound debriding) to be applied directly to the wound bed on the left hip or saturate gauze with the ointment and place in the wound bed. The wound was to be covered with dry gauze and secured with tape.

Nursing documentation revealed that the medication was administered but the record lacked evidence of the left hip wound having been addressed in the nursing notes and/or on the shift skin assessments until three (3) days after the medication was ordered, seven (7) days after the patient's admission. In addition, the wound was not addressed in the notes or shift skin assessments on day nine (9) and day ten (10) of a twelve (12) day hospitalization.

An interview at 3:30 p.m. on 04/06/2011 in the administrative conference room with the Program Director (RN) confirmed that the medical record lacked evidence of nursing staff having documented the pressure sore on the left hip until seven (7) days after admission. The nurse also confirmed that the transfer form the facility received at the time of transfer was available to staff and had indicated the patient had a left hip wound.


A review of the wound nursing records revealed that on the day after admission the wound care nurse documented that the patient had muscle and skin graft site to the right lateral hip area. The patient had a wound vac in place and the nurse re-applied the wound vac after assessing the areas. Three (3) days later the wound nurse documented that the wound vac was in place and the dressings remained intact. Four (4) days later, seven (7) days after admission, the wound nurse documented an unstageable pressure ulcer over coccyx area and indicated it was the pressure ulcer that had been documented at previous facility where it was referred to as left hip area.

An interview at 2:14 p.m. on 04/06/2011 in the administrative conference room with the wound care nurse confirmed that, after reviewing the on-line medical record, the nurse was aware that the patient had a pressure sore on the left hip when transferred from previous facility. The nurse also confirmed that the initial wound assessment revealed no evidence of a pressure wound on the left hip. The interviewee was unable to explain why the pressure sore on the left hip had not been addressed on the initial wound assessment.