HospitalInspections.org

Based on document review and interview, the hospital failed to ensure wound care for 2 of 10 patients (P7 and P9) was provided in accordance with policies and/or provider orders.

Findings include:

1. Review of hospital policies indicated the following:
A. Policy WC II-2, titled "Wound Assessment (CIRH)", indicated the following: All patient admitted will have a skin assessment within 8 hours of admission, skin will be assessed every shift, and every 7 days during the comprehensive wound assessment. The assessment of a wound will include at a minimum location, size, tunneling, undermining, drainage, odor, color, and surrounding tissue. Wound size: Measurement should include length, width, and depth of the wound.
B. Policy WC II-7, titled "Wound Documentation (CIRH)", indicated the following: Wound treatment orders are initiated in the medical record per physician order or protocol/algorithm. Dressing changes and wound site care are documented in the MR (medical record) or EMR (electronic medical record). Documentation of prevention strategies including ointments, lotions, barrier creams, etc. may be on the Kardex or within the 24 hour flowsheet (FS) and plan of care/EMR.

2. Medical record review:
A. Review of the MR/EMR for patient P7 indicated the following: The patient admitted to the hospital on 7/9/22 at 1335 hours as a transfer from Hospital HA. The initial wound assessment was done on 7/9/22 at 1454 hours by Registered Nurse N6 and indicated the patient presented with 4 (four) wound as follows: 1. Pressure injury left heel (PIHL) - stage 2, < 25% wound bed covered; 2. Pressure injury sacrum (PIS) - stage 1, intact skin; 3. Head-Parietal (incision), anterior; left (HPL) - Exudate - none, Closure - sutures; and 4. Laceration/Mouth; right (LMR) - Partial thickness tissue loss, 75 to 100 % of wound filled and/or tissue overgrowth, Exudate amount - scant, Odor - none. The four wound assessments lacked documentation of measurements/size(s) of the wounds as per policy. Wound Progress Notes (PN) indicated the admission evaluation was performed on 7/11/22 at 10:42 AM by Wound Team Nurse (WTN) N1. The PN lacked evidence/documentation of measurements/sizes of the 4 wounds.
Wound Management orders entered 7/9/22 at 1459 hours indicated the following: 1. Associated Wounds: PIHL(heel): Daily (and as needed [prn]) - cleanse with normal saline (NS), apply medihoney, cover with mepilex. MR documentation lacked evidence of the PIHL wound having been cleansed daily prior to 7/11/22 at 1024 hours (documented 7/12/22 at 1351 hours). Unable to determine the PIHL wound was covered with mepilex due to conflicting documentation. The 7/11/22, 1024 hour entry, recorded on 7/12/22 at 1351 hours indicated the wound was open to air. The 7/12/22 at 0900 hour entry recorded on 7/12/22 at 1240 hours indicated the PIHL (heal) wound was covered with foam. The MR also lacked documentation of the heel wound having been daily cleansed, treated, and/or dressed per orders on (not all inclusive) 7/15/22, 7/16/22 and/or 7/17/22.
Wound Management orders on 7/12/22 at 1334 hours: Associated Wounds: PIS (sacrum), 2x/d - apply zinc ointment. The MR lacked documentation of zinc ointment having been applied 2x/d to the PIS (sacrum) on dates as follows (not all inclusive): 7/15/22, 7/16/22, and/or 7/17/22. Wound Progress Note, date of service 7/25/22 at 1038 hours indicated the sacrum wound now had serosanguineous drainage and wound management would include NS, skin prep and if pain, may apply medical grade honey. The MR lacked evidence of new orders for wound care of the PIS. The MR/FS indicated that on 7/26/22 per the 0800 entry, wound care of the PIS included medical grade honey and a foam dressing. The entry lacked documentation of NS cleanse/use. The MR/FS lacked documentation of wound care for the PIS having been provided on 7/27/22 and/or 7/28/22.
Wound Management orders on 7/12/22 at 1334 hours: Associated Wounds: HPL (head), 2 times daily (2x/d) - cleanse entire suture line with Hibiclens and leave open to air. The MR lacked documentation of the HPL wound having been cleansed with Hibiclens 2x/d on dates as follows (not all inclusive): 7/12/22, 7/13/22, 7/15/22, 7/16/22, 7/17/22. Nursing Note, date of service 7/18/22 at 1:42 PM, indicated the following: "Crani" wound to left head...skin becomes unapproximated and tissue visualized is yellow/green and has foul odor. Moderate amount serous drainage noted from site. This RN reported to physician who stated to have wound RN assess site. Wound RN notified. The MR lacked documentation of a WTN having reassessed the patient after that time on that date; the next WTN assessment/Wound PN was dated 7/25/22. Wound Management orders 7/18/22 at 1357 hours: Associated Wounds: HPL, 2x/d - cleanse entire suture line with Hibiclens, paint incision with betadine and leave open to air. FS/MR documentation lacked documentation of order implementation as follows (not all inclusive): The MR lacked evidence of wound care to the head with application of betadine on 7/19/22, 7/20/22 lacked documentation of wound care 2x/d and the 0800 entry lacked documentation of the wound having been cleansed and/or betadine applied. On 7/21/22, the MR/FS lacked documentation of 2x/d wound care to the head and the 0800 hour entry indicated medical grade honey and a silicone dressing was applied. Wound Progress Note, date of service 7/25/22 at 1038 hours indicated the HPL wound depth had increased from 0 cm (centimeters) at admission to 0.8 cm. Recommendations: cranial incision with dehiscence noted, area measures 5 x 1 x 0.8 (no unit of measure was indicated), no drainage noted, area cleansed and covered with medihoney and mepilex. Wound Management orders 7/25/22 at 1233 hours: Associated Wounds: HPL, 2x/d - Cleanse entire suture line with Hibiclens, paint incision with betadine and leave open to air was included in the comments. Additional questions/answers of the order indicated the wound was to be cleansed with NS, the site prepped with skin prep, fill/apply medical grade honey/paint approximated incision with betadine, fill as needed with saline moistened gauze and cover with adhesive foam. The FS/MR lacked documentation of 2x/d wound care of the head per orders as follows: The 7/26/22 0800 hour entry lacked documentation of the wound having been cleansed and/or painted with betadine; on 7/26/22, the MR/FS lacked evidence of 2x/d wound care. On 7/27/22, the MR/FS lacked documentation of wound care. Wound Management orders 8/1/22 at 1817 hours: Associated Wounds: HPL, 2x/d - Cleanse with NS, prep with skin prep and allow to dry, fill as needed with saline moistened gauze (paint approximated incision with betadine), cover with adhesive foam. The FS/MR lacked evidence of nursing having followed HPL wound care orders as follows (not all inclusive): The FS/MR lacked documentation of 2x/d wound care on 8/4/22, 8/6/22, 8/7/22, 8/8/22 and 8/9/22. The 8/6/22, 2000 hours entry of HPL wound care indicated the dressing was reinforced and lacked evidence of the wound having been cleansed and/or painted as per orders.
Wound PN, date of service 8/10/22 at 4:46 PM lacked evidence of the LMR (mouth) wound weekly/comprehensive assessment.

B. The MR of patient P9, admitted 7/1/22 at 1918 hours and discharged 9/14/22, indicated the following: Initial wound care orders dated 7/1/22 at 1927 hours indicated an order was placed for Wound/Ostomy evaluation and treatment. Nursing FS documentation 7/2/22 at 0103 hours indicated the patient had a surgical wound to the upper midline of the abdomen with a wound vac (vacuum) in place for NPWT (Negative Pressure Wound Therapy/Treatment). Wound PN, date of service 7/5/22 at 10:30 AM by WTN RN N2, lacked documentation of an assessment which included the size and characteristics of the wound. Wound Management orders 7/5/22 at 1926 hours: Associated Wounds: Surgical Wound Quadrant, abdomen Upper; Midline. Interval: Every Monday (M), Wednesday (W), Friday (F). Wound management: NPWT. Cavilon, contact layer, foam, specialized foam. Pressure type/Setting: Continuous at 125 mmHg (millimeters of mercury). Wound PN, date of service 7/6/22 at 11:23 hours by RN N4 indicated the dressing was changed; the PN lacked documentation of wound measurements. FS/MR documentation of dressing changes lacked evidence of dressing changes having been performed as per orders (the entries lacked evidence/documentation of use of Cavilon and/or dressing type) on the following dates (not all inclusive): 7/11/22, 7/13/22, 7/15/22, 7/18/22, and 7/20/22. New orders for the surgical abdominal wound on 8/26/22 at 1710 hours indicated: Every MWF: cleanse with NS, prep with skin prep and allow to dry, fill/apply xeroform, cover with ABD (abdominal wound dressing). FS/MR documentation lacked clear evidence/documentation of MWF dressing changes from 8/31/22 to 9/7/22.

3. On 10/6/22, beginning at approximately 3:30 PM, A3, Quality Control/Interim Chief Nursing Officer (CNO) verified MR findings for patients P7 and P9.