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Based on record review and interview, the facility failed to assess and evaluate a patient's wound care needs in one (SP#1) of 11 sampled patients as twice ordered by the physician.

The findings include:

Review of the Doctors' orders dated 2-8-11 showed that there was an order written for Wound Care Evaluation. There was no documentation that this was done from the time the original order was written. On 2-14-11, another order for Wound Care Evaluation and Treatment was written. No documentation was seen in the patient's chart that this was done.

Interview with the Chief Nursing Officer (CNO) conducted on 5-4-11 at 1100am revealed that an order is entered into the computer and this generates a transaction number. The order is received by the Wound Care Nurse (WCN) . The CNO did not find nor could locate in the chart for any documentation that the Wound Care Evaluation and Treatment was done as ordered.

Interview with the WCN conducted on 5-4-11 at 1105am revealed that she did not receive the first (1st) order (from 2-8-11) and the Log that she had with her did not contain it. She could not state a reason for this happening. The order from 2-14-11 was received by her and was filed in the Log at the time of the interview. The WCN stated that she went to see SP#1 on 2-14-11. She noted that the patient had facial bruises but does not remember seeing any laceration and the patient had a dry and callused area on the right heel. She noted SP#1 was on an air mattress and that the heel protectors were in use. She also stated that she checked the patient's back. According to the WCN, she did not write or document any assessments and /or findings on SP#1 and she admitted that she did not communicate with the patient's nurse that day. The reason from the WCN as to why she did not document in the chart is because " it is not a chronic wound ". The interview ended at 1150am.

The facility's Wound Care Prevention and Management Protocol states as its Purpose: To identify those patients with actual or potential alterations in skin integrity and institute corrective measures in a planned, organized, systematic manner. The protocol further states that one of the responsibilities of the Wound Coordinator or Wound/Ostomy Nurse is to provide clinical consultation to nursing in management of skin integrity, including pressure ulcer treatment, management of surgical and draining wounds and ostomy care. Consultative services include the provision of clinical education for management of skin integrity, patient specific assessment of alterations in skin integrity and recommendation of treatment considerations to nursing and medical staff and photo documentation of wounds.

Interview with the CNO and WCN on 5-4-11 at 1200pm confirmed the above findings that the order for Wound Care Evaluation and Treatment was not followed up from the time the original order (2-8-11) by the nursing staff until a repeat order was written on 2-14-11, that there was no documentation by the WCN of her evaluation of SP#1 and that the WCN did not inform the patient's nurse that she saw the patient.

Liwanag, Lillian
Based on record review and interview, the facility failed to include results of wound care consultative evaluation in one (SP#1) of 11 sampled patients as ordered twice by the physician.

The findings include:

Review of the Doctors' orders dated 2-8-11 showed that there was an order written for Wound Care Evaluation. There was no documentation that this was done from the time the original order was written. On 2-14-11, another order for Wound Care Evaluation and Treatment was written. No documentation was seen in the patient's chart that this was done.

Interview with the Chief Nursing Officer (CNO) conducted on 5-4-11 at 1100am revealed that an order is entered into the computer and this generates a transaction number. The order is received by the Wound Care Nurse (WCN) . The CNO did not find nor could locate in the chart for any documentation that the Wound Care Evaluation and Treatment was done as ordered.

Interview with the WCN conducted on 5-4-11 at 1105am revealed that she did not receive the first (1st) order (from 2-8-11) and the Log that she had with her did not contain it. She could not state a reason for this happening. The order from 2-14-11 was received by her and was filed in the Log at the time of the interview. The WCN stated that she went to see SP#1 on 2-14-11. She noted that the patient had facial bruises but does not remember seeing any laceration and the patient had a dry and callused area on the right heel. She noted SP#1 was on an air mattress and that the heel protectors were in use. She also stated that she checked the patient's back. According to the WCN, she did not write or document any assessments and /or findings on SP#1 and she admitted that she did not communicate with the patient's nurse that day. The reason from the WCN as to why she did not document in the chart is because " it is not a chronic wound ". The interview ended at 1150am.

The facility's Wound Care Prevention and Management Protocol states as its Purpose: To identify those patients with actual or potential alterations in skin integrity and institute corrective measures in a planned, organized, systematic manner. The protocol further states that one of the responsibilities of the Wound Coordinator or Wound/Ostomy Nurse is to provide clinical consultation to nursing in management of skin integrity, including pressure ulcer treatment, management of surgical and draining wounds and ostomy care. Consultative services include the provision of clinical education for management of skin integrity, patient specific assessment of alterations in skin integrity and recommendation of treatment considerations to nursing and medical staff and photo documentation of wounds.

Interview with the CNO and WCN on 5-4-11 at 1200pm confirmed the above findings that the order for Wound Care Evaluation and Treatment was not followed up from the time the original order (2-8-11) by the nursing staff until a repeat order was written on 2-14-11, that there was no documentation by the WCN of her evaluation of SP#1 and that the WCN did not inform the patient's nurse that she saw the patient.

Based on observation and interview, the facility failed to perform a regular periodic maintenance and testing program for the medical equipment (thermometer) used in patient care to ensure an acceptable level of safe patient care.

The findings include:

Observation during the tour of the 2nd floor Telemetry Unit conducted on 5-4-11 at 2pm revealed that Rm233 was a vacant private room. Observation revealed the presence of a blood pressure machine and thermometer in the room. It was observed that the Preventive Maintenance sticker on the blood pressure machine was current (10-11) while the sticker on the thermometer was noted to be outdated (7-10). The Chief Nursing Officer (CNO) was immediately made aware of the findings. She called the Director of Telemetry to verify what the preventive maintenance sticker (7-10) meant.

Interview with the Director of Telemetry conducted during the tour on 5-4-11 at 205pm revealed that the preventive maintenance sticker which read "7-10" meant July 2010. She stated that preventive maintenance of thermometers are scheduled and done every six months. She also confirmed that these particular equipments (blood pressure machine and thermometer) in Rm233 at the time of the tour were currently used for taking the patients' vital signs.

Interview with the Biomed Staff conducted during the tour on 5-4-11 at 210pm identified the particular thermometer as one included in the CNL (cannot locate) list. He explained that this thermometer has been a CNL item for 3 months now. He explained that preventive maintenance is done every 6 months - equipments are sent to the Biomed office where preventive maintenance is performed. He added that a CNL list is forwarded to the CNO and/or Unit Director; request orders are sent; and then back to Biomed for the work order.

Interview with the CNO conducted during the tour on 5-4-11 at 215pm confirmed that preventive maintenance for thermometers are scheduled and performed every six months. She confirmed that the thermometer is currently used on the Unit for taking the patient's temperature. She also confirmed that the thermometer's preventive maintenance has been missed and is long overdue.

Based on record review and interview, the facility failed to assess and evaluate a patient's wound care needs in one (SP#1) of 11 sampled patients as twice ordered by the physician.

The findings include:

Review of the Doctors' orders dated 2-8-11 showed that there was an order written for Wound Care Evaluation. There was no documentation that this was done from the time the original order was written. On 2-14-11, another order for Wound Care Evaluation and Treatment was written. No documentation was seen in the patient's chart that this was done.

Interview with the Chief Nursing Officer (CNO) conducted on 5-4-11 at 1100am revealed that an order is entered into the computer and this generates a transaction number. The order is received by the Wound Care Nurse (WCN) . The CNO did not find nor could locate in the chart for any documentation that the Wound Care Evaluation and Treatment was done as ordered.

Interview with the WCN conducted on 5-4-11 at 1105am revealed that she did not receive the first (1st) order (from 2-8-11) and the Log that she had with her did not contain it. She could not state a reason for this happening. The order from 2-14-11 was received by her and was filed in the Log at the time of the interview. The WCN stated that she went to see SP#1 on 2-14-11. She noted that the patient had facial bruises but does not remember seeing any laceration and the patient had a dry and callused area on the right heel. She noted SP#1 was on an air mattress and that the heel protectors were in use. She also stated that she checked the patient's back. According to the WCN, she did not write or document any assessments and /or findings on SP#1 and she admitted that she did not communicate with the patient's nurse that day. The reason from the WCN as to why she did not document in the chart is because " it is not a chronic wound ". The interview ended at 1150am.

The facility's Wound Care Prevention and Management Protocol states as its Purpose: To identify those patients with actual or potential alterations in skin integrity and institute corrective measures in a planned, organized, systematic manner. The protocol further states that one of the responsibilities of the Wound Coordinator or Wound/Ostomy Nurse is to provide clinical consultation to nursing in management of skin integrity, including pressure ulcer treatment, management of surgical and draining wounds and ostomy care. Consultative services include the provision of clinical education for management of skin integrity, patient specific assessment of alterations in skin integrity and recommendation of treatment considerations to nursing and medical staff and photo documentation of wounds.

Interview with the CNO and WCN on 5-4-11 at 1200pm confirmed the above findings that the order for Wound Care Evaluation and Treatment was not followed up from the time the original order (2-8-11) by the nursing staff until a repeat order was written on 2-14-11, that there was no documentation by the WCN of her evaluation of SP#1 and that the WCN did not inform the patient's nurse that she saw the patient.

Liwanag, Lillian
Based on record review and interview, the facility failed to include results of wound care consultative evaluation in one (SP#1) of 11 sampled patients as ordered twice by the physician.

The findings include:

Review of the Doctors' orders dated 2-8-11 showed that there was an order written for Wound Care Evaluation. There was no documentation that this was done from the time the original order was written. On 2-14-11, another order for Wound Care Evaluation and Treatment was written. No documentation was seen in the patient's chart that this was done.

Interview with the Chief Nursing Officer (CNO) conducted on 5-4-11 at 1100am revealed that an order is entered into the computer and this generates a transaction number. The order is received by the Wound Care Nurse (WCN) . The CNO did not find nor could locate in the chart for any documentation that the Wound Care Evaluation and Treatment was done as ordered.

Interview with the WCN conducted on 5-4-11 at 1105am revealed that she did not receive the first (1st) order (from 2-8-11) and the Log that she had with her did not contain it. She could not state a reason for this happening. The order from 2-14-11 was received by her and was filed in the Log at the time of the interview. The WCN stated that she went to see SP#1 on 2-14-11. She noted that the patient had facial bruises but does not remember seeing any laceration and the patient had a dry and callused area on the right heel. She noted SP#1 was on an air mattress and that the heel protectors were in use. She also stated that she checked the patient's back. According to the WCN, she did not write or document any assessments and /or findings on SP#1 and she admitted that she did not communicate with the patient's nurse that day. The reason from the WCN as to why she did not document in the chart is because " it is not a chronic wound ". The interview ended at 1150am.

The facility's Wound Care Prevention and Management Protocol states as its Purpose: To identify those patients with actual or potential alterations in skin integrity and institute corrective measures in a planned, organized, systematic manner. The protocol further states that one of the responsibilities of the Wound Coordinator or Wound/Ostomy Nurse is to provide clinical consultation to nursing in management of skin integrity, including pressure ulcer treatment, management of surgical and draining wounds and ostomy care. Consultative services include the provision of clinical education for management of skin integrity, patient specific assessment of alterations in skin integrity and recommendation of treatment considerations to nursing and medical staff and photo documentation of wounds.

Interview with the CNO and WCN on 5-4-11 at 1200pm confirmed the above findings that the order for Wound Care Evaluation and Treatment was not followed up from the time the original order (2-8-11) by the nursing staff until a repeat order was written on 2-14-11, that there was no documentation by the WCN of her evaluation of SP#1 and that the WCN did not inform the patient's nurse that she saw the patient.

Based on observation and interview, the facility failed to perform a regular periodic maintenance and testing program for the medical equipment (thermometer) used in patient care to ensure an acceptable level of safe patient care.

The findings include:

Observation during the tour of the 2nd floor Telemetry Unit conducted on 5-4-11 at 2pm revealed that Rm233 was a vacant private room. Observation revealed the presence of a blood pressure machine and thermometer in the room. It was observed that the Preventive Maintenance sticker on the blood pressure machine was current (10-11) while the sticker on the thermometer was noted to be outdated (7-10). The Chief Nursing Officer (CNO) was immediately made aware of the findings. She called the Director of Telemetry to verify what the preventive maintenance sticker (7-10) meant.

Interview with the Director of Telemetry conducted during the tour on 5-4-11 at 205pm revealed that the preventive maintenance sticker which read "7-10" meant July 2010. She stated that preventive maintenance of thermometers are scheduled and done every six months. She also confirmed that these particular equipments (blood pressure machine and thermometer) in Rm233 at the time of the tour were currently used for taking the patients' vital signs.

Interview with the Biomed Staff conducted during the tour on 5-4-11 at 210pm identified the particular thermometer as one included in the CNL (cannot locate) list. He explained that this thermometer has been a CNL item for 3 months now. He explained that preventive maintenance is done every 6 months - equipments are sent to the Biomed office where preventive maintenance is performed. He added that a CNL list is forwarded to the CNO and/or Unit Director; request orders are sent; and then back to Biomed for the work order.

Interview with the CNO conducted during the tour on 5-4-11 at 215pm confirmed that preventive maintenance for thermometers are scheduled and performed every six months. She confirmed that the thermometer is currently used on the Unit for taking the patient's temperature. She also confirmed that the thermometer's preventive maintenance has been missed and is long overdue.