HospitalInspections.org

Based on document review and interview, the nurse executive failed to ensure nursing staff follow their policy/procedure for wound assessment, prevention and documentation for 1 of 10 closed medical records reviewed.

Findings include:

1. Policy/procedure QCE-002, Wound Assessment, Prevention and Documentation, revised/reapproved 8/17/16 indicated on page 5: "b. Daily documentation of skin and wound inspection completed by an RN will include any of the following, if present: i. skin condition, ii. dressing integrity, iii. description of wound drainage, odor, pain, signs of inflammation or infection".

2. Review of patient 1's medical record (MR) lacked documentation of daily wound assessment of patient 1's right thigh surgical incision wound on 5/18/17.

3. Review of patient 1's MR indicated nursing staff provided wound treatment/dressing changes to patient 1's right thigh surgical incision wound on 5/19/17 at 1205 hours, 5/20/17 at 0800 hours, 5/21/17 at 0800 hours, 5/22/17 at 1600 and 2145 hours. Patient 1's MR lacked documentation of wound treatment/dressing changes to patient's right thigh surgical incision wound on 5/18/17. Frequency of wound treatments and dressing changes could not be determined due to lack of physician orders for wound care for dates 5/18/17 to 5/22/17.

4. Staff N1 (Nurse Manager) was interviewed on 7/18/17 at approximately 1230 and confirmed patient 1's MR lacked documentation per nursing staff of patient 1's right thigh surgical incision wound assessment. Staff N1 confirmed nursing staff changed patient 1's right thigh surgical incision wound dressing on 5/19/17 at 1205 hours, 5/20/17 at 0800 hours, 5/21/17 at 0800 hours and 5/22/17 at 1600 and 2145 hours without a physician's order. Staff N1 confirmed nursing staff should follow physician's orders for wound treatments and dressing changes.