HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to provide wound care as ordered to 1 of 2 (Patient #2) sampled patients reviewed with pressure ulcers.

The findings included:

Medical record review for Patient #2 revealed the patient was admitted to the hospital on 12/11/14 after being transferred from a Palliative Care Unit in another city. The patient's diagnosis included recurrent rectal cancer with large ulceration status post chemotherapy and radiation therapy and Human Immunodeficiency Virus.

Review of the facility policy for Skin and Wound Care revealed, " ...Staff nurse should carry out these orders between the wound care nurse visits ... "

Review of the "All Orders Report - Detail " from 12/11/14-5/17/16 revealed a physician's order dated 12/11/14, "Check drainage prn [as needed] perineal medial gluteal fold, lt [left] scrotum wound care daily and prn excessive drainage - Pt [Patient] must be premedicated for pain prior to care. Apply lidocaine to wound prior to care prn, may need to wait 10-15 minutes before proceeding. Clean wound with NS [normal saline], pat dry with gauze Apply metro gel to calcium alginate and lay in wound bed, over with ABD [abdominal] pads. Do not tape, secure with mesh panties when available ... "

On 12/15/14 an order was written to "check dressing to lt pretib [pre-tibial] every other day and PRN. Change dressing lt pretib once weekly and prn soiling or dislodgement ... "

Orders on 12/15/14 at 15:26 revealed , " ...WOUND CARE TWICE DAILY ...Wound care for perineum and posterior to sacrum Premedicate prn prior to tx [treatment]. Irrigated and cleanse daily with NS, pack deeper part of wound with maxorb with a small amount of metro gel and lidocaine on side that will be applied to wound, lay dry maxorb over sacral ulcer. Cover with ABD pads only. Change ABD pads at bedtime prn ... "

On 12/22/14 the physician ordered, "Wound care every 3-4 days and prn for rt [right] pretib and lt calf-clean with NS or wound cleanser, cover with tegaderm to rt pretib, optifoam to rt calf ... " There was no order to discontinue wound care to the sacral ulcer that was ordered twice a day.

Review of the Shift Activity Report dated 12/17/14 revealed a dressing change was done to the sacral wound at 13:40 (1:40 PM). There was documentation at 14:23 (2:23 PM) and 16:28 (4:28 PM) that nursing performed, "WOUND CARE TWICE DAILY." There was no documentation at 14:23 or 16:28 which wounds were addressed.

Documentation on 12/19/14 revealed wound care to the sacrum was performed once, at 16:29.

On 12/20/14 at 12:40 PM, the nurse documented "WOUND CARE TWICE DAILY ... WOUND CARE ORDERS DAILY ... Dressing removed. Moderate amount drainage noted. Cleaned and redressed as ordered ..." There was no documentation of which wound the dressing change was performed on.

On 12/21/14 and 12/22/14, documentation revealed wound care was provided to the sacral wound only once per day.

There was no documentation of any wound care provided to the patient on 12/23/14 or 12/24/14. The patient was discharged from the facility on 12/24/14 at 6:43 PM.


During an interview in the Administrative Conference Room on 5/17/16 at 12:44 PM, the Clinical Informatics Nurse verified there was no documentation of wound care on 12/23/14 or 12/24/14.

Based on policy review and observation, the facility failed to ensure infection control measures were performed to prevent the transmission of infection and communicable disease for 1 of 1 (5/18/16) observation days.

The findings included:

1. Review of the facility policy, "Infection Control", revealed, "...Handwashing...when-...before and after patient contact, before donning and after removing gloves..."

2. Observations on 5/18/16 at 8:35 AM on the second floor revealed Nurse #3 performing medication pass. The nurse washed her hands and donned gloves before administering medications, including a subcutaneous injection. After removing her gloves, the nurse exited the room and took the medication cart to the nurses station. The nurse never washed her hands after removing her gloves.