HospitalInspections.org

Based on record review and interview, the facility failed to evaluate the wound status and wound care needs of one (#1) of 10 sampled patients (SP) provided by the judgment and specialized skill of a Wound Care Nurse.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted on 6-16-11 revealed that she was admitted to the facility on 4-12-11 at 2335 due to rectal bleeding. Documentation on the Admission Interdisciplinary History Assessment completed on 4-13-11 at 0315 revealed the need for a wound care evaluation due to a "left arm bruise and a right ankle Stage I with redness." There was no documented evidence of an evaluation done by the Wound Care Nurse up to the time of discharge. There was no documented evidence that the Staff Nurses on the Unit followed-through the referral for wound care evaluation.

Interview with the Wound Care Nurse conducted on 6-16-11 at 430pm confirmed that there was no wound care evaluation done on SP#1.

Based on record review and interview, the facility failed to show proof that medications were administered as ordered by the physician in one (#5) of 10 sampled patients (SP).

The findings include:

Clinical record review of SP#5 conducted on 6-16-11 revealed that he was admitted to the facility due to abdominal pain. Documentation showed physician orders dated 4-1-11 at 0255 which included "Flagyl 500milligrams IV [intravenous] every 8 hours." There was no documented evidence that Flagyl was given on 4-1-11 at 2200 and 4-2-11 at 0600.
Documentation showed physician orders dated 4-3-11 at 1530 which included "Questran 1 pack orally every 8 hours." There was no documented evidence that Questran was given on 4-4-11 at 1400.

Interview with the Chief Nursing Officer conducted on 6-16-11 at 3pm confirmed that there was no way of knowing whether the medications were given or not because the times for the respective medications were left unmarked. She stated that the standard of practice is to cross out the time and sign initials to prove that the medication was administered; and to encircle the time, sign initials and write the reason to show why the medication was not given.

Based on record review and interview, the facility failed to evaluate the wound status and wound care needs of one (#1) of 10 sampled patients (SP) provided by the judgment and specialized skill of a Wound Care Nurse.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted on 6-16-11 revealed that she was admitted to the facility on 4-12-11 at 2335 due to rectal bleeding. Documentation on the Admission Interdisciplinary History Assessment completed on 4-13-11 at 0315 revealed the need for a wound care evaluation due to a "left arm bruise and a right ankle Stage I with redness." There was no documented evidence of an evaluation done by the Wound Care Nurse up to the time of discharge. There was no documented evidence that the Staff Nurses on the Unit followed-through the referral for wound care evaluation.

Interview with the Wound Care Nurse conducted on 6-16-11 at 430pm confirmed that there was no wound care evaluation done on SP#1.

Based on record review and interview, the facility failed to show proof that medications were administered as ordered by the physician in one (#5) of 10 sampled patients (SP).

The findings include:

Clinical record review of SP#5 conducted on 6-16-11 revealed that he was admitted to the facility due to abdominal pain. Documentation showed physician orders dated 4-1-11 at 0255 which included "Flagyl 500milligrams IV [intravenous] every 8 hours." There was no documented evidence that Flagyl was given on 4-1-11 at 2200 and 4-2-11 at 0600.
Documentation showed physician orders dated 4-3-11 at 1530 which included "Questran 1 pack orally every 8 hours." There was no documented evidence that Questran was given on 4-4-11 at 1400.

Interview with the Chief Nursing Officer conducted on 6-16-11 at 3pm confirmed that there was no way of knowing whether the medications were given or not because the times for the respective medications were left unmarked. She stated that the standard of practice is to cross out the time and sign initials to prove that the medication was administered; and to encircle the time, sign initials and write the reason to show why the medication was not given.