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ENCOMPASS HEALTH REHABILITATION HOSPITAL, PARTNER
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on staff interview, record review and policy and procedure review, the facility failed to ensure the Wound Care Nurse followed the facilities policy and procedure, "Wound Assessment and Documentation," for documentation of wound measurements a minimum of weekly in one (1) out of three (3) medical records reviewed; Patient #3.
Findings Include:
Cross Refer to A-0467; 482.24 (c)(1) for the facility's failure to ensure complete and accurate documentation of patient care.
During Exit Conference on 02/24/2022 at 2:10 p.m. survey findings were discussed, and no further documentation was submitted for review.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
A-0467
482.24 (c)(1)
Based on staff interview, record review, and policy and procedure (P&P) review, the facility failed to ensure a complete and accurate medical record was maintained for 1 (one) out of 3 (three) medical records reviewed; Patient #3.
Findings include:
During an interview on 02/24/2022 at 10:45 a.m. the Wound Care Nurse confirmed Patient #3's wife refused to allow wound care "a few times". The Wound Care Nurse confirmed that she did not measure and document the wounds weekly per facility policy, but instead takes photographs of wounds to show progress.
During an Interview on 02/24/2022 at 11:50 a.m. the Educator/Infection Control Nurse (EICN), confirmed that the Wound Care Nurse is still in training and did not follow facility policy, "Wound Assessment and Documentation" for wound measurements and documentation no less frequently than weekly.
During an interview on 02/24/2022 at 12:05 p.m. with the Director of Quality/Risk Manager (DQR), it was revealed that she would expect the wound care nurse to know and follow the policies and procedures.
Review of the medical record for Patient #1 revealed there was no evidence of documentation of weekly wound measurement the week(s) of 11/29/2021, 12/6/2021 and 12/13/2021 from the Wound Care Nurse.
Review of facility's "Wound Assessment and Documentation" Policy (dated 5/19/2021, reviewed 11/11/2021) revealed that " .... I. Assessment ...2 ...D. Pressure injuries/ulcers will be staged, measured, and photographed in accordance with the wound treatment plan, but not less than weekly. E. Within 2 days before discharge a final complete assessment is conducted, including descriptions, staging, measuring, and photography as appropriate ..."
During Exit Conference on 02/24/2022 at 2:10 p.m. survey findings were discussed, and no further documentation was submitted for review.