HospitalInspections.org

Based on record review and staff interview the Registered Nurse failed to ensure appropriate nursing care for 6 (#1, #4, #5, #6, #8, #10) of 10 sampled patients related to wound care, intravenous therapy, and implementing physician orders. This practice does not ensure patient's goals are achieved.

Findings include:

1. Patient #1 was admitted to the facility on 5/28/11. Review of nursing documentation revealed the following inconsistencies related to the skin assessments. On 6/9/11 at 8:00 a.m. the wounds were documented on the sacrum, buttocks, right upper extremity and right heel. On 6/11/11 at 9:00 p.m. only the sacral wounds were assessed. On 6/12/11 only the sacral wounds were assessed. On 6/13/11, the wound appearance of the wound bed of an open wound was not documented. On 6/16/11 at 7:30 p.m. and 6/17/11 at 8:26 a.m. and 7:30 p.m. there was no assessment of the condition of the skin. On 6/18/11 at 8:00 a.m. there was no assessment of the wound on the heel. On 6/18/11 at 7:15 p.m. and on 6/19/11 at 8:10 p.m. there was no assessment of the skin.

The wound care nurse was consulted on 6/15/11 and documented that the sacral wound was unstagable as it was covered with yellow slough. Until that time, the nursing staff had documented nursing interventions such as an alternating air mattress, turning every two hours and floating of the heels.

The patient was transferred from the Intensive Care Unit to the Progressive Care Unit on 6/16/11. On 6/16/11 after the patient was transferred, there was no documentation of the pressure ulcer prevention interventions. There was also no documentation of the interventions on 6/17/11 and 6/18/11.

The Chief Nursing Officer confirmed the above findings during interview on 7/1/11 at approximately 3:30 p.m.

2. Review of the medical record of patient #10 revealed the following inconsistencies regarding skin assessment. On 6/29/11 at 9:00 p.m. wounds were identified on the left forearm and left heel, but the appearance of the wound was not documented. On 7/1/11 at 6:27 a.m. and 8:00 a.m. the assessment of the wound on the left heel was not documented. The finding was confirmed by the nursing director on 7/1/11 at 3:20 p.m.


The facility's policy "Intravenous Therapy" # IV 001, last revised 11/10, required that the assessment of the Intravenous (IV) site be done every 4 hours.

3. Review of the medical record of patient #4 revealed no intravenous (IV) site assessment on 6/29/11 at 8:00 p.m. and at midnight on 7/1/11. The nursing director confirmed the finding on 7/1/11 at 10:45 a.m.

4. Review of the medical record of patient #5 revealed a Peripherally Inserted Central Catheter (PICC) line was inserted on 6/29/11. Review of nursing documentation revealed no assessment of the site on 6/30/11 at noon or 4:00 p.m. and none on 7/1/11 at midnight. The nursing director confirmed the finding on 7/1/11 at 11:30 a.m.

5. Review of the medical record for patient #6 revealed lack of IV assessment on 6/30/11 at midnight , 4:00 a.m., noon, 6:00 p.m. On 7/1/11 at midnight, 4:00 a.m. and 8:00 a.m. The nursing director confirmed the findings on 7/1/11 at 12:20 p.m.

6. Review of the medical record for patient # 8 revealed no IV assessment on 6/30/11 at midnight and 4:00 p.m. On 7/1/11 at midnight and 4:00 a.m. The nursing director confirmed the findings on 7/1/11 at 1:55 p.m.

7. Review of the medical record of patient #4 revealed the physician had written an order for sequential compression devices (SCD) to the lower extremities on 6/29/11. Review of the nursing documentation on 6/29, 6/30 and 7/1/11 revealed no evidence the SCDs were in place. The nursing director confirmed the findings on 7/1/11 at 2:40 p.m.

8. Review of the medical record for patient #6 revealed the physician wrote an order for blood glucose monitoring every 4 hours on 6/29/11. Review of nursing documentation revealed documentation on 6/29/11 at 10:19 a.m., 5:51 p.m. and 10:24 a.m. There was no additional documentation of blood glucose monitoring on 6/30/11 or 7/1/11. There was no evidence the physician had discontinued the order. The nursing director confined the finding on 7/1/11 at 12:20 p.m.