Corrective Action Plan Provider Number 38-0051

Oregon Department of Human Resources Complaint Numbers OR6875 and OR6831

RESPONSE TO PREFIX TAG A 395

CFR 482.23(8)(3) RN SUPERVISION OF CARE
A registered nurse must supervise and evaluate the nursing care for each patient.
This STANDARD is not met as the hospital failed to ensure that the registered nurse evaluated all of the patient's nursing care needs on admission and throughout the hospitalization. There was a lack of initial and on-going assessment related to 6 of 6 alterations of the patient's skin conditions. The Hospital implemented a new electronic clinical documentation system for nursing assessment on admission, reassessment by as defined by hospital policies, nursing care plans, and patient education in February, 2011. The Hospital's Skin Care Team, recognizing that documentation of skin and wound assessment and care planning were complicated and at times not completed because of the complexity of data entry and staff was not well educated on the electronic documentation tools related to wound assessment and care prior to the time of this investigation. The Team had already petitioned the Clinical Documentation Council to redesign the electronic tools to improve ease of use. The Plan of Correction was developed in collaboration with the Skin Care Team.

Plan of Correction:
Review current skin assessment and wound documentation in the electronic medical record (EMR) and design future state EMR documentation workflow. (Done 8/15/2011) 2. The Skin Integrity Record and the Wound Assessment Record which includes the photograph of the wound will remain in paper forms in the EMR; electronic communication "reminders" will be designed in the EMR to refer the nursing staff to review the forms, transcribe the initial wound assessment in the EMR, and update as necessary. 3. Per the CMS Present on Admission rule, physicians are required to stage pressure ulcers. If this form is not completed on admission when the physician is not present or during emergent or urgent situations when the form cannot be completed, a electronic note to the physician to review/complete the Wound Integrity Record will appear at the time the physician signs into the EMR. 4. A check box and "document wound assessment in Epic" (the EMR) will be placed on the Wound Integrity Record as a visual cue to nursing staff reminding them that the initial assessment needs to be in Epic. 5. Review/revise the Skin Care and Wound Care/Skin Integrity-Photo documentation/Evidence Collection policies to combine all skin and wound assessment and care into one single policy entitled Wound Care Protocol to provide consistency of information for staff. 6. Educate all clinical staff who assess and treat wounds on the new EMR documentation workflows and policy changes via didactic, and coaching, mentoring by Epic SuperUsers. 7. The Skin Care Team members will monitor compliance for all patients during Skin Care Rounds conducted in each patient care unit biweekly. Audits will continue in all units until 95% compliance is reached, and sustained for two months Data will be shared with unit staff and management team, and reported to the Staff Practice Council regularly. 8. Metrics are: a. #completed skin assessments completed per policy/#total patients reviewed b. #completed Wound Assessment Records completed/#total patients reviewed 1.

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Corrective Action Plan Provider Number 38-0051
c. d.

Oregon Department of Human Resources Complaint Numbers OR6875 and OR6831

#completed Skin Integrity Records/ #total patients reviewed #completed wound documentations completed per identified wound/#total patients with wounds.

Responsible Person:

Kristin Haydon, BSN, RN, BC Director Clinical Excellence and Medical Unit, and Nursing Director Liaison to the Skin Care Team October 18, 2011

Completion Date:

RESPONSE TO PREFIX TAG A 396

CFR 482.23(b)(4) NURSING CARE PLAN The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. This STANDARD is not met as evidenced by that an individualized care plan for alterations in the patient's skin condition was developed and kept current by the nursing staff, and based on the assessment of the patient and identified patient needs.

Plan of Correction:

1. Design, test, and implement Wound Care plan of care in the EMR.
2. 3. Include care plan in the education to be provided ( #6 of page 1 of this document). The Skin Care Team members will monitor compliance for all patients during Skin Care Rounds conducted in each patient care unit biweekly. Audits will continue in all units until 95% compliance is reached, and sustained for two months Data will be shared with unit staff and management team, and reported to the Staff Practice Council regularly. Metric: #wound care plans completed per policy/#total patients with wounds.

4.

Responsible Person:

Kristin Haydon, BSN, RN, BC Director, Clinical Excellence and Medical Unit, and Nursing Director Liaison to Skin Care Team October 18, 2011

Completion Date: