HospitalInspections.org

Based on medical record review, policy review and staff interview the facility failed to develop policies in the area of patient assessment frequencies of pressure sores. This affected three of three patient's with pressure sores of whose medical records were reviewed. (Patient #s 1, 2, and 3) The facility census was 7 on 4/22/10.

Findings include:

Review of the medical records of patient #s 1, 2, and 3 revealed there was no care plans developed for the measurement of pressure sores for these patients. Review of the facility's policies revealed the policies lacked how often pressure sores were to be measured to determine if the current treatments were effective. The policies did not specify pressure sore protocols that had been adopted by the hospital. Interview of staff #1 on 4/22/10 at 1:30 PM revealed the facility follows a protocol developed by a brand name company that lists the company's treatments using the company products. Staff #1 further revealed these protocols were not listed in the hospital's policies and were not referenced to in the facility's policies.

RE-CITE

Based on medical record review and staff interview the facility failed to meet the nursing needs for two of three patients whose records were reviewed that had been admitted to the hospital with impaired skin integrity. (Patient #s 2 and 3 ) The patient census was 7 on 4/22/10.

Findings include:

Review of the medical record for patient #2 on 4/22/10 revealed this patient was admitted to the facility on 3/10/10 until discharge 3/19/10. The patient was admitted with six, stage two (open) pressure sores located on a 3rd toe that measured 4 by 3 millimeters, on the great toe measuring 6 by 9 millimeters, on the right outer leg measuring 1 by 1 millimeter,on the right buttock measuring 1 by 1 millimeter, on the left buttock measuring 1 millimeter by 1 and 1/2 millimeters, and on the right heel measuring 1 by 1 1/2 millimeters. There were no physicians orders that specified the treatment that needed to be completed for each of these open areas. There were no further measurements of this patient's wounds. There was no way to determine if these wounds had improved, stayed the same, or worsened.
Interview of facility staff #1 on 4/22/10 at 1:35 PM confirmed this finding.

Review of the medical record of patient #3 on 4/22/10 revealed the patient had been admitted to the facility on 3/12/10 and discharged on 3/18/10. The record revealed the patient had been identified as having a black area on the 5th right toe upon admission to the facility. There was no documented evidence there had been a treatment prescribed for this area by the physician nor any documentation a treatment or assessment of this area had been completed by the nurse since the patient's admission on 3/12/10. There was no plan of care for the treatment and on-going assessment of this affected area.
Interview of facility staff #1 on 4/22/10 at 1:35 PM confirmed these findings.


RE-CITE

03193






07312

Based on medical record review and staff interview the facility failed to develop a pressure sore care plan for two of three patients whose records were reviewed that had been admitted to the hospital with impaired skin integrity. (Patient numbers 2 and 3 ) The patient census was 7 on 4/22/10.

Findings include:

Review of the medical record for patient #2 on 4/22/10 revealed this patient was admitted to the facility on 3/10/10 until discharge 3/19/10. The patient was admitted with six, stage two (open) pressure sores located on a 3rd toe that measured 4 by 3 millimeters, on the great toe measuring 6 by 9 millimeters, on the right outer leg measuring 1 by 1 millimeter,on the right buttock measuring 1 by 1 millimeter, on the left buttock measuring 1 millimeter by 1 and 1/2 millimeters, and on the right heel measuring 1 by 1 1/2 millimeters. There were no physicians orders that specified the treatment that needed to be completed for each of these open areas. There were no further measurements of this patient's wounds. There was no way to determine if these wounds had improved, stayed the same, or worsened. There was no care plan that identified the specific treatments that were to be provided for each of the pressure sore areas. There was no plan of care developed to assess the progress or lack of progress of these pressure sore areas.

Review of the medical record of patient #3 on 4/22/10 revealed the patient had been admitted to the facility on 3/12/10 and discharged on 3/18/10. The record revealed the patient had been identified as having a black area on the 5th right toe upon admission to the facility. There was no documented evidence there had been a treatment prescribed for this area by the physician nor any documentation a treatment or assessment of this area had been completed by the nurse since the patient's admission on 3/12/10. There was no plan of care for the treatment and on-going assessment of this affected area.

Interview of facility staff #1 on 4/22/10 at 1:35 PM confirmed these findings.

RE-CITE