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Based on record review and interview, the hospital failed to provide care in a safe setting, in that, 1 of 1 patient (Patient #6) developed a wound on his right shin during his hospitalization. There was no documentation of when and how the wound occurred.


Findings included:

The medical record was reviewed on 10/9/2014 in the conference room. The medical record indicated Patient #6 was in the facility for 10 days (June 26-July 5) with a diagnosis of decline in functional status, uremic myopathy, end-stage renal disease on peritoneal dialysis, and status post orthotopic heart transplantation.

The attending physician Staff #17 noted in a progress note on 7/4/2014: "Medical status: No new complaints except that the wound on the right leg is draining serous fluid."

Patient #6's medical record did not include information regarding when and how the wound occurred.

Based on record review and interviews, the hospital failed to have the patient's care supervised and evaluated by a registered nurse in that,

A. 1 of 1 patient (Patient #6) had wounds on his arms upon admission that occurred from a fall. The wound assessment for these wounds was not documented every shift.

B. 1 of 1 patient (Patient #6) sustained a new wound on his right shin. There was no documentation of how the wound occurred, no wound care orders, and no documented ongoing assessment of the wound by the nursing staff according to the hospital's policy.

Findings included:

The medical record of Patient #6 was reviewed on 10/9/2014 in the conference room.

A. The nurse's notes indicated for 10 days (June 26 - July 5) that Patient #6 was in the facility, there was no documentation that the wounds on Patient #6's arms were measured and assessed according to the hospital's wound care protocol.

Consult notes by Staff # 21 on 6/30/2014, for the wounds on the upper extremities stated..."full thickness tissue loss in the medial volar aspect of his left arm. This is just superior to the medial epicondyle. This wound is irregular with some foul thick drainage. There is also some mild induration. There is some minimal peri-wound erythema. The right hand dorsal aspect has full thickness tissue loss that appears to be from traumatic injury. It is irregular in shape. The wound base has some necrotic devitalized tissue. There is a very scant amount of drainage here."

During an interview with Staff #8 and #19 via telephone on 10/8/2014 at 9:00 PM, both staff members stated that Patient #6 had wounds and they stated that there is a wound protocol and a wound care sheet.

B. The attending physician (Staff #17) noted in a progress note on 07/04/14, "Medical status: No new complaints except that the wound on the right leg is draining serous fluid."

The nurse's notes indicated that for 10 days (June 26-July 5) that Patient #6 was in the facility, there was no documentation how the wound occurred, no documentation that the physician or family was notified by the nurse of the new wound, and no new orders for wound care for the right shin.

During an interview with Staff #4 and #20 in the conference room on October 9, 2014 at 11:30 AM, both staff members did not recall there being a wound on Patient #6's right shin on the days that they provided care for Patient #6.

Review on 10/9/2014 in the Conference room of the Nursing policy for Skin tears Policy Number RH-NU-122 Revised date of 1/13/2012 stated "...The physician must be notified of the presence of skin tear and whenever there is an adverse change in skin tear status."
"...Assessment and documentation of dressing and skin tear status are performed every shift and during dressing changes."
"...Patient management:
1. Assess skin tear based on the following:
a. Measurement of length and width in centimeters.
b. Exudates
i. Amount: low, moderate, high
ii. Type: serosanguineous, serous, sanguineous, purulent, seropurulent
c. Odor: present or absent
2. Implement skin tear precautions for patients with frail skin and/or risk for falls:
3. Local Wound care as per physicians's orders."