HospitalInspections.org

Based on observation, interview and record review the facility failed to follow the facility policy for wound documentation for three open patients (Patients #8, #11 and #12) of five patients sampled with wounds. The facility census was 28.

Findings included:

1. Review of the facility policy titled "Wound Prevention Care and Documentation" original date of 10/2008 revealed in part:
Procedure:
I. Assessment, Documentation and Establish a Plan of Care:
A. Assess and document the patient's skin for alteration in integrity and risk for breakdown on admission using the Nursing Admission Assessment.
C. If the patient has a stage II (open break in the skin) or greater: Document your initial findings on the Nursing Admission Assessment and Nursing Daily documentation. Daily findings including dressing change of all wounds. Clinical observations of wound status as well as dressing change procedure should be documented with in the Nursing Daily documentation.
1. At a minimum, photo documentation must be completed using the following guidelines:
c. Take a photograph upon initial and duration of the healing process.
2. Number the wound and document location and onset date.
5. Size: Measure the wound (open surface area and depth) weekly and record in centimeters.

2. Open record review for Patient #8 revealed the patient entered the facility on 7/14/10.

Patient #8's Nursing Admission Assessment dated 7/14/10 revealed a one centimeter (cm) stage II area to the back of the right thigh just below the buttock.

Hospital Admission Orders dated 7/14/10 revealed under wound care: healing stage II open to air and monitor.

The chart contained no photographs from admission to current of the wound noted on admission to the back of the upper right thigh.

Nursing Assessments revealed under the skin inspection section:
-On 7/15/10 the 7AM shift and the 7PM shift both documented skin not intact to the right buttock (not upper right thigh).
-On 7/16/10 and 7/17/10 the 7AM shift and the 7PM shift both documented skin intact.
-On 7/18/10 the 7AM shift noted skin not intact but did not note where the not intact skin was located. The 7PM shift noted skin intact.
-On 7/19/10 and 7/20/10 both the 7AM and 7PM shift noted skin to the right posterior (back) thigh not intact
-On 7/21/10 the 7AM shift noted skin not intact to the posterior thigh. The 7PM shift noted skin intact.

The Interdisciplinary Progress Notes (used for Nursing Daily Documentation) dated 7/14/10 to 7/21/10 did not address the wound status or skin assessments.

Observation on 7/22/10 at 3:30 PM revealed Patient #8 had a small pink open area to the back of the right upper thigh just below the buttocks.

Interviews revealed:
-On 7/22/10 at 3:30 PM during skin observation, Staff J, Register Nurse (RN) said the orders for Patient #8 were to leave the wound open to air. Staff J said he/she worked weekends and thought the staff measured wounds on Tuesdays. Staff J said the nurses were to document on the wounds in the Interdisciplinary Progress notes.

3. Open record review for Patient #11 revealed the patient entered the facility on 7/7/10.

Patient #11's Nursing Admission Assessment dated 7/7/10 revealed a 1X1 cm stage II wound to the right buttock.

Hospital Admission Orders dated 7/16/10 revealed an order for wound care per protocol.

Nursing Assessments under the skin inspection section revealed on 7/8/10 a stage II to buttock, non intact skin on the 7AM and 7PM shift. On 7/9/10 thru 7/21/10 the skin inspection section documentation was either blank or noted the skin to be intact.

Patient #11's medical record contained a photograph of patient's right buttock area on 7/10/10 (three days after admission). The medical record had no other photographs of the wound.

Patient #11's Interdisciplinary Progress Notes did not address the wound to the right buttock noted on the 7/7/10 Nursing Admission Assessment again until 7/10/10. Progress note on 7/10/10 revealed coccyx excoriated, red and flaky with no open areas noted.

Observation on 7/22/10 at 10:50 AM revealed Patient #11's buttocks red with no open areas.

4. Open record review for Patient #12 revealed the patient entered the facility on 7/7/10.

Patient #12's Nursing Admission Assessment dated 7/7/10 noted an area to the right buttock. The area was numbered #1, but did not describe the wound as intact or not intact and/or the wound size.

Hospital Admission Orders dated 7/7/10 revealed silver sulfadiazine cream (antibacterial cream used to treat burns) to the stage I (non open area) to coccyx and leave open to air.

Nursing Assessments under the skin inspection section revealed:
-On 7/7/10 not intact skin on the 7PM shift, but did not document where the wound was located and/or the size.
-On 7/8/10 on the 7AM shift not intact skin stage II to the buttocks and scrotum, but noted intact on the 7PM shift.
-On 7/9/10 thru 7/12/10 the documentation was either blank or noted the skin to be intact.
-On 7/13/10 not intact skin to the buttocks was noted for the 7AM and 7PM shift.
-On 7/14/10 intact skin to the left buttocks (healed) for the 7AM and 7PM shift.
-On 7/15/10 and 7/16/10 the 7AM and 7PM shift noted skin intact.
-On 7/17/10 and 7/18/10 not intact stage II area to the posterior scrotum for both 7AM and 7PM shift.
-On 7/19/10 7AM shift noted skin intact, but not intact on 7PM shift.
-On 7/20/10 and 7/21/10 skin noted as not intact for both 7AM and 7PM shift.

Interdisciplinary Progress notes revealed on 7/7/10 a stage II area on buttocks but did not address the wound status or treatment to the area again thru the current date.

Patient #12's medical record did not have any photographs of any wounds.

Observation on 7/22/10 at 3:20 PM revealed red buttocks with no open area.

-On 7/22/10 at 4:00 PM Staff B, Director of Patient Care Services stated staff were to document any wounds on admission on the Nursing Admission Assessment. Staff B said this includes the size and the location. Staff B said staff then document daily on the Nursing Assessment if the wound is intact or not intact and then document in the Interdisciplinary Progress Notes the wound status including the size and treatment or if it is healed. Staff B said photos of the wounds should be done on admission if there is a wound, when a wound is discovered, with significant change to the wound and at discharge. Staff B said staff had not been documenting or photographing patient's wounds according to the facility policy.