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Based on record review, facility policy review and staff interview, the facility failed to perform/document an assessment of a wound for 1 of 10 sampled records (Patient 3). The facility census was 35.

Findings are:

A. Patient 3 admitted on 11/30/18 from an outside hospital. The admitting diagnosis included wound care; pulmonary hypertension (a rise in blood pressure in the arteries that go from your heart to your lungs.); end-stage renal disease (The kidneys fail and stop working.) and a abdominal wound closure requiring a wound vac (a vacuum-assisted closure of a wound that helps the wound heel by decreasing air pressure on the wound.).

A review of Patient 3's wound documentation identified:
1) That upon admission on 11/30/18 that a registered nurse (RN) did a head to toe assessment of the patients skin. That assessment revealed a wound vac to the abdomen; peri-rectal IAD (incontinence associated dermatitis- an inflammation and/or erosion of the skin associated with exposure to urine or stool.) and Calmoseptine( an ointment applied to protect the skin from irritation from urine or stool). Sacral silicone (a foam dressing to the tailbone area to protect the skin from breakdown) applied for prevention; offload heels with pillows; generalized rash throughout the body was noted.
2) On 12/3/18, a wound nurse (WN A) did a head to toe wound assessment. The assessment revealed an abdominal - surgical wound measuring 15.5 cm (centimeters) x 1.7 com and 2.8 cm deep. (pictures were taken for documentation) and the perineum improved.
3) On 12/10/18, WN A did a head to toe wound assessment. The assessment revealed an abdominal wound measuring 21 cm x 1.5 cm and 1.8 cm deep and R) (right) arm wound measuring 2.3 cm x 4.1 cm. (pictures were taken for documentation).
4) On 12/17/18, WN A did a head to toe wound assessment. The assessment revealed an abdominal wound was completed and R) (right) arm wound measuring 2.2 cm x 5.0 cm and unstageable ( a full thickness tissue loss in which the base of the wound is covered by slough or eschar (dead tissue covering wound). (pictures were taken for documentation).

The medical record lacked identification of the right arm wound on 11/30/18 and 12/3/18.

A review of Patient 's Orders identified:
1) On 11/30/18 a Wound Progress note sticker was placed in the Physician Progress notes and signed off by the physician as noted. The sticker identified, "Abdominal Wound: Head to toe assessment. Wound vac to abdomen. Peri rectal IAD-applied calmoseptine. Sacral Silicone applied for prevention. Offload heels with pillows. Generalized rash through body". The RN received the following orders at 1610 (4:10 PM), sacral silicone drsg (dressing), Change every 3 days and as needed; Abdominal wound per wound vac at NPWT (negative-pressure wound therapy) at 125 mmHg(a millimeter of mercury-a measurement unit of pressure) continuous and change on Monday-Wednesday-Friday.
2) On 12/3/18 a Wound Progress note sticker was placed in the Physician Progress notes and signed off by the physician as noted. The sticker identified, Abdominal-surgical: Head to toe assessment. see pics (pictures) for assessment; perineum improved. No new orders received.
3) On 12/10/18 a Wound Progress note sticker was placed in the Physician Progress notes and signed off by the physician as noted. The sticker identified, Abdominal wound; R) arm. Head to toe assessment complete. see pics. No new orders received.
4) On 12/17/18 a Wound Progress note sticker was placed in the Physician Progress notes and signed off by the physician as noted. The sticker identified, Abdominal wound; R) arm. Head to toe assessment complete. see pics. No new orders received.

A review of the 24 hour Patient Record and Plan of Care (Notes that the nurses chart on throughout their shifts) revealed:
-Review of the 11/30/18 24 hour Patient Record and Plan of Care and the Admission Database and Plan of care lacked identification of any of the wounds. Per staff on admission the Wound Nurse or House Supervisor does the head to toe assessment and documents on their forms. The form identified the patient had 2 IJ (internal jugular vein) catheters (a small tube inserted into the internal jugular vein in the neck of the patient for a dependable intravenous access). The left IJ is used for a continuous infusion of a medication Remodulin (special medication that treats pulmonary artery hypertension by widening the blood vessels); the right IJ is used for hemodialysis (filtering the blood to remove wastes when the patient has kidney failure).
-Review if the 12/18/18 24 hour Patient Record and Plan of Care identified the patient had a subclavian (same as the left IJ) catheter on the left; HD (hemodialysis) catheter on the right (same as the right IJ); and a ML (Midline an intravenous catheter inserted in an upper arm large vein).

An interview with WN A on 12/19/18 at 11:15 AM revealed, "the right arm wound was not seen on the initial or the 12/3/18 head to toe assessment. I did find it on 12/10/18 head to toe assessment, I asked the patient and the spouse if they knew where it came from. The patient and spouse thought it may have been there at the previous hospital but they were unsure how it got there." When we do a head to toe assessment, we look at all of the patients skin without clothing on. "If the wound nurse has left for the day, the house supervisor does the assessment." When asked what the treatment for the right upper inner arm wound was, the WN A stated, "leaving it open to air."

An observation on 12/19/18 at 12:35 PM of Patient 3's right upper inner arm wound showed an oval shaped wound with irregular edges and was tan/brown leathery appearing wound.

A review of a Progress Note dated 11/30/18 at 9:58 AM from a physician at the previous hospital identified on the physical exam, the Right IJ tunneled HD catheter and the Left IJ tunneled catheter with both sites "ok"; Extremities with no edema; and skin as no lesions or rashes on exposed area.

A review of the Transition Orders and Information for the Continuation (transfer information) of Patient Care from the previous hospital for Patient 3 dated 11/30/18 revealed:
-Lines/Drains/Airway status as Wound Vac to abdomen; HD to Right IJ; tunneled Left IJ.
-Active Skin Alterations as Abdomen medial midline abdominal incision.
The Transition Orders and information for the continuation of Patient care lacked any documentation of the right upper inner arm wound.

A review of the Wound Assessment Policy and Procedure dated 1/17 revealed:
-All patients admitted will have a skin assessment within 8 hours of admission and skin will be assessed every shift.
-Patients admitted for wound care will have a comprehensive assessment of the wound on admission and within 7 days thereafter. The assessment of a wound will include at a minimum location, size, tunneling, undermining, drainage, odor, color, and surrounding tissue. Pressure ulcers/injuries will be staged by the Wound Nurse/Charge Nurse who have completed education and competency requirements for staging (usually house supervisors or charge nurses).
-Photographs of the wound will be taken on admission, within 7 days and at discharge (within 1 day before discharge) as part of the wound assessment.
-Additionally, at admission and discharge, all abnormal, non-intact, non-healthy skin will be photographed.
-Unstageable: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Based on record review, facility policy review and staff interview, the facility failed to follow the facility policy and have a second access intravenous site available for a critical drip medication Remodulin (used to treat pulmonary hypertension- a rise in blood pressure in the arteries that go from your heart to your lungs) from 11/30/18-12/5/18 for 1 of 10 sampled records (Patient 3). The facility census was 35.

Findings are:

A. Patient 3 admitted on 11/30/18 from an outside hospital. The admitting diagnosis included wound care; pulmonary hypertension; end-stage renal disease (The kidneys fail and stop working.) and a abdominal wound closure requiring a wound vac (a vacuum-assisted closure of a wound that helps the wound heel by decreasing air pressure on the wound.).

A review of Patient 3's medical record revealed:
-Remodulin 22 mg (milligrams) /ml (milliliters) IV daily. This medication is delivered via a small pump worn on the body. The medication is delivered continuously through the left IJ (internal jugular vein) catheters (a small tube inserted into the internal jugular vein in the neck of the patient for a dependable intravenous access).
-A review of the 24 hour Patient Record and Plan of Care (Notes that the nurses chart on throughout their shifts) revealed that from 11/30/18 through the afternoon of 12/5/18 the 24 hour Patient Record and Plan of Care patient identified Patient 3 had 2 IJ catheters; a left IJ that was used for a continuous infusion of a medication Remodulin and the right IJ is used for hemodialysis (filtering the blood to remove wastes when the patient has kidney failure).
-A review of the 24 hour Patient Record and Plan of Care revealed that from the afternoon of 12/5/18 24 through 12/19/18 the 24 hour Patient Record and Plan of Care identified the patient had a subclavian (same as the left IJ) catheter on the left; HD (hemodialysis) catheter on the right (same as the right IJ); and a ML (Midline an intravenous catheter inserted in an upper arm large vein).
-A review of the nurses notes on 12/5/18 revealed that the midline IV was inserted per protocol.
-A review of the physician orders dated 12/5/18 at 1100 revealed, "OK for midline by PICC Nurse (peripherally inserted central catheter- a nurse that is trained to insert central line catheters), may use lidocaine (a medication that numbs the skin when inserting the catheter into the vein)."

A review of the Policy and Procedure CRITICAL DRIP: TREPROSTINIL (REMODULIN) INFUSION, revealed:
-It is essential that Treprostinil therapy NEVER be interrupted except for tubing/bag changes. Any other disconnection from the infusion (e.g., bathing, imaging, testing) must be approved by the physician.
-If administered IV, a second IV access point should be maintained at all times. The backup access line can be peripheral if needed.
-If administered IV, treprostinil should be administered through a central line - if you should have problems with the patient's central line, a new central catheter should be scheduled for placement as soon as possible. A peripheral line can be used temporarily if needed.

An interview with the Registered Pharmacist Director (RP) for the facility on 12/19/18 at 2:00 PM stated, "The patient needs to have the 3rd line and that is why they had the midline inserted (12/5/18) because they need to have a backup access." When asked why the patient did not have the 3rd line from admission on 11/30/18 through the afternoon of 12/5/18, the RP stated, "(Patient 3) should have, that is per the policy."

An interview with the Quality Manager on 12/19/18 at 2:15 PM verified there was no 3rd IV line prior to the midline being inserted on 12/5/18.