HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failing to initiate wound care treatment after pressure wounds identified (#1) and by failing to ensure skin and wound assessments were completed timely, per hospital policy, and accurately for 2 (#1, #3) of 3 sampled patients.
Findings:

Review of the hospital policy titled Initial Assessment/Reassessment of Wounds, with last approved and effective date of 05/2023 revealed, in part:
Policy: To provide guidelines for assessment and reassessment of wounds by the RN and/or Wound Care Nurse.
Wounds will be: 2. Assessed and by the admitting RN or Wound Care Nurse within 8 hours of admission.
3. Assessed by the Wound Care Nurse (if applicable) within 24-48 hours of admission.

1. Review of Patient #1's medical record revealed an admit date and time of 02/01/2024 at 16:50. Patient #1 had diagnoses of sepsis, stage 4 sacral wound, osteomyelitis, and diabetes mellitus type 2.

Review of Patient #1's admit skin/wounds assessment completed by the RN on 02/02/2024 at 03:53 revealed, in part, pressure wounds to right heel and coccyx.

Review of Patient #1's initial Wound Care Nurse assessment dated 02/02/2024 revealed, in part, pressure wounds to left heel, coccyx, sacrum, right buttocks, right hip, and right great toe.

In an interview on 11/04/2024 at 12:06 p.m., S2DON confirmed Patient #1's admit skin/wounds assessment not completed by RN within 8 hours of admission as per hospital policy. S2DON confirmed Patient #1's admit skin/wounds assessment done by the RN on 02/02/2024 at 03:53 did not capture Patient #1's pressure wounds to left heel, sacrum, right buttocks, right hip, and right great toe. S2DON confirmed Patient #1 did not have a right heel pressure wound.

Review of Patient #1's initial Wound Care Nurse assessment dated 02/02/2024 revealed, in part, pressure wounds to left heel, coccyx, sacrum, right buttocks, right hip, and right great toe. Further review revealed assessment of left heel and right foot pressure wounds were not entirely completed by the wound care nurse until 02/07/2024.

In an interview on 11/04/2024 at 12:08 p.m., S2DON confirmed Patient #1's admit Wound Care Nurse assessment of left heel and right foot pressure wounds not completed within 24-48 hours of admission.

Review of Patient #1's medical record revealed orders dated 02/06/2024 for wound care treatment to left medial heel and right great toe.

In an interview on 11/04/2024 at 1:32 p.m., S2DON confirmed Patient #1 had wounds to left heel and right great toe when assessed on 02/02/2024. S2DON confirmed treatment orders for Patient #1's wounds to left heel and right great toe should have been obtained after the assessment on 02/02/2024 and treatment started. S2DON confirmed there was no evidence Patient #1's left heel and right great toe were treated until orders obtained on 02/06/2024.

2. Review of Patient #3's medical record revealed an admit date and time of 10/22/2024 at 19:22. Patient #3 had diagnoses of acute and chronic respiratory failure and sepsis.

Review of Patient #3's RN skin/wounds assessments completed each shift from 10/22/2024 to 10/30/2024 revealed the patient had no wounds present.

Review of Patient #3's initial Wound Care Nurse Assessments dated 10/31/2024 revealed, in part, unstageable pressure wound to right buttock measuring 5.5 cm length, 3.3 cm width, 0.1 cm depth and unstageable pressure wound to coccyx measuring 3 cm length, 2 cm width, 0.1 cm depth.

In an interview on 11/06/2024 at 10:27 a.m., S3ADON confirmed Patient #3's RN skin/wounds assessments did not document any wounds from 10/22/2024 to 10/30/2024. S3ADON confirmed Patient #3 had pressure wounds to right buttock and coccyx that were noted on the initial wound care nurse assessments 10/31/2024.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include wounds in the plan of care for 2 (#1, #3) of 3 sampled patients with wounds.
Findings:

Review of the hospital policy titled Plan of Care, with last approved and effective date of 09/2024 revealed, in part:
After a thorough nursing assessment is done, Care Plans are initiated by an RN. The Care Plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals.

1. Review of Patient #1's medical record revealed an admission date of 02/01/2024 with admitting diagnoses of stage 4 sacral wound. Further review revealed Patient #1 had pressure wounds to left heel, coccyx, sacrum, right buttocks, right hip, and right great toe.

Review of Patient #1's plan of care revealed pressure wounds was not addressed as an identified problem on the patient's care plan.

In an interview on 11/06/2024 at 11:04 a.m., S3ADON confirmed pressure wounds was not identified as a problem on Patient #1's care plan.

2. Review of Patient #3's medical record revealed an admission date of 10/22/2024 with admitting diagnoses of acute and chronic respiratory failure and sepsis. Further review revealed Patient #3 had unstageable pressure wounds to right buttock and coccyx.

Review of Patient #3's plan of care revealed pressure wounds was not addressed as an identified problem on the patient's care plan.

In an interview on 11/06/2024 at 11:09 a.m., S3ADON confirmed pressure wounds was not identified as a problem on Patient #3's care plan.