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MEMORIAL HERMANN HOSPITAL SYSTEM
NURSING CARE PLAN
Tag No.: A0396
Based on record review and interview, facility nursing staff failed to provide daily wound care and position the patient every two hours; per doctor's orders and plan of care for one (1) of five (5) patients (patient ID # 1).
Findings include:
Record review of medical record of Patient (ID#1), doctors' orders on 2/2/2017 at 4:49 p.m. revealed: daily, clean sacral wound with NS (normal saline), apply thick layer of Santyl collagenase to wound followed by NS moist fluffed gauze dry gauze, ABD pad, secure with Medipore tape. Change daily.
Record review of Patient's (ID #1) nursing notes dated 2/2/2017 to 2/21/2017 revealed daily dressing changes were not completed on the following days: 2/4/2017, 2/5/2017, 2/8/2017, 2/12/2017, 2/15/2017, 2/16/2017, 2/19/2017 and 2/20/2017.
Interview on 6/27/2017 at 1:30 p.m. with the Patient Safety Specialist, Staff (ID #91), RN, stated "it appears wound care was not completed every day. The wound care order was written for every day. Yes, it should have been completed".
Record review of current facility policy "Patient Assessment, Data Collection and Nursing Documentation Guideline" dated 6/6/2016 stated the nursing process is used to individualize the care ...documented aspects of nursing care provided to the patient ....
Record review of nursing notes from 1/16/2017 to 2/17/2017 revealed the following documentation related to the patient's positioning:
Staff ID #58, RN documents on the nursing notes flow sheet on 1/23/2017 at 7:30 a.m. "independent" (related to positioning).
Staff ID #70, RN, documents on 1/30/2017 10:00 p.m., and on 1/31/2017 at 12:00 a.m. "able to shift positions independently".
Staff ID # 77, RN, documents on 2/7/2017 at 12:35 p.m.; "Chair position, up in chair" and on 2/7/2017 at 4:47 p.m.; "Head of bed, elevated, right".
Interview on 2/27/2017 at 2:00 p.m. with the Nurse Manager, (Staff ID # 63), RN, stated it is an expectation that patients are turned. All patients are placed on an air mattress.
Record review of facility policy "Pressure Ulcer Prevention and Management Procedure" dated 1/24/2017 stated RN, LVNs (Licensed Vocational Nurses), PCAs (Patient Care Assistants), PCTs (Patient Care Technicians) -Repositioning- It is imperative that the patient be turned on a regular schedule, taking care to keep pressure off of the affected area(s) and bony prominences.