HospitalInspections.org

Based on clinical record review and staff interview it was determined the registered nurse failed to supervise and evaluate care to ensure care was provided according to physician orders for 1 (#1) of 10 sampled patients. This practice does not ensure patient goals are met and may lead to a prolonged hospital stay.

Findings include:

Patient #1's incision/wound assessments revealed dressing changes were completed on
a) On 5/24/12 at 12:00 a.m. the dressing to the right leg and right groin incisions were changed. An ABD pad, gauze kerlix and non adherent dressings were applied.
b) On 5/24/12 at 6:00 a.m. the dressing was changed on the right leg, using ABD pad, gauze petroleum, and gauze wrap.
c) On 5/24/12 at 3:00 p.m. the dressing was changed to the right leg using an ABD pad, Gauze kerlix and non adhesive dressing
d) On 5/25/12 at 6:00 a.m. the dressing to the right leg incision was changed using an ABD pad and Gauze kerlix. The dressing to the right groin was changed using a non adherent transparent dressing.
e)On 5/25/12 at 3:00 p.m. the dressing was changed to the right leg, (no description of dressing documented)
f) On 5/26/12 at 5:00 a.m. the dressing to the right leg incision was changed using gauze 4x4 and gauze kerlix.
g) On 5/26/12 at 3:00 p.m. the dressing to the right leg incision was changed using a non adhesive gauze dressing
h) On 5/27/12 at 5:40 a.m. the right groin dressing was changed using a gauze 4x4, gauze kerlix and an non adhesive transparent dressing.
i) On 5/27/12 at 10:15 p.m. the right leg incision dressing was changed using an ABD pad, gauze 4x4, non adhesive dressing. The right groin incision dressing was changed using an ABD pad, gauze 4x4 and gauze kerlix.
j) On 5/27/12 at 11:10 p.m. the dressing was changed to the right leg incision. There was no description of the dressing change
k)On 5/28/12 at 1:00 a.m. the right leg incision dressing was changed using an ABD pad, Gauze 4x4 and non adhesive dressing.
l) On 5/28/12 at 5:11 a.m. the dressing was changed to the right leg using an ABD pad, gauze 4x4, and non adhesive dressing
m) On 5/28/12 at 3:00 a.m. the dressing was changed to the right leg incision using an ABD pad, gauze 4x4, and non adhesive dressing
n) On 5/28/12 at 3:00 p.m. a dressing change was completed on the right 4th toe using a wet to dry dressing.
o) On 5/29/12 at 4:00 a.m. the dressing was changed on the right 4th toe using an ABD pad, gauze ,4x4 and tape. Optifoam dressing was used on excoriated skin on right groin, silver nitrate on a bleeding site.

Patient #1's physician's orders dated from 5/22/12 to discharge on 6/2/12 revealed no orders for wound care or dressing changes. Nursing documentation dated from 5/22/12 to discharge on 6/2/12 revealed the physician had not been notified to obtain orders for wound care or dressing changes.

An interview was conducted with the Director of Quality on 7/13/12 at approximately 3:00 p.m. and the lack of physicians orders and notifying the physician for orders for dressing changes was confirmed.