Every finding on record at Colquitt Regional Hospice

Based on record reviews, staff interview, and review of policy titled ";Wound Documentation," it was determined the agency failed to update the comprehensive assessment with wound care documentation for two patients (P) (17, P19) of 19 patients sampled. --- Findings include: Review of facility policy titled ";Wound Documentation," revised June 2018, reveals the following: Purpose It shall be the policy of the agency to provide clinical guidelines for documentation of wounds, to promote healing/comfort through managing wounds in accordance with physician orders. Documentation Document wound assessment, treatment and response to treatment in clinical record. Wound assessment may include but is not limited to: 1. Location 2. Measure as able 3. Amount of necrotic tissue 4. Amount of drainage 5. Condition of per-wound 6. Presence of odor 7. signs/symptoms of infection or wound deterioration 8. Patient/Caregiver teaching 9. Physician notification as appropriate 1. Review of the clinical nurse's note dated 9/04/2024 revealed that P17 had a stage 2 wound to sacral area. The nurse failed to document measurements, presence or absence of necrotic tissue, amount/type of drainage, condition of peri-wound, presence of odor, signs/symptoms of infection or wound deterioration, and patient teaching. 2. Review of the clinical nurse's note dated 8/29/24 revealed that P19 had wound on Right hip and wound on Left hip. The nurse failed to document measurements, presence or absence of necrotic tissue, amount/type of drainage, condition of peri-wound, presence of odor, signs/symptoms of infection or wound deterioration, and patient teaching. During an interview on 9/24/24 at 2:00 pm with the Administrator, it was confirmed that the agency did not update the comprehensive assessment per the wound care policy with wound documentation on P17 and P19. The Administrator was unable to provide supporting wound documentation.