HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to complete pressure sore assessments for 1 of 10 sampled patients (#1).

Findings:

Patient #1's nurse's note from 9/13/14 at 8 AM read, "Tear. Location: Buttocks. Wound eval: open." A nurse's note from 9/15/14 at 9:35 AM read, "Tear. Location: Buttocks. Wound eval: Open. Surround Tissue Eval: Red. Slight purplish. Wound bed: Black. Purple.... Dressing: Mepilex Boarder. Drainage amt.: small. Drainage type: serous.."

Patient #1's Wound Care nurse's note of 9/15/15 at 5:34 PM read, "New wound care nurse note for new skin problem/coccyx. Patient noted with linear deep tissue purple discoloration with open epidermis on sacral/coccyx.... Staff to notify family and PCP regarding new PU (pressure ulcer)."

A review of facility policy "Pressure Ulcer Prevention and Care Guidelines" read, "Measure wound size in centimeters. Measure length, width and depth." There was no evidence in the medical record that this directive was followed throughout the patient's stay with respect to the open wound buttocks site.

During an interview of the Director of Risk Management on 6/12/15 at approximately 5:15 PM, she confirmed the findings.

Based on interview and record review, the facility failed to ensure that topical medication patches were given according to physician's order for 1 of 10 sampled patients (#1).

Findings:

Patient #1's Medication Administration Record indicated that a topical Fentanyl Patch 50 MCG (micrograms)/HR (hour) for 72 hours, was applied on 9/19/14 at 10:04 AM. This was the last patch application, as it was cancelled through physician orders on 9/20/14. However, there was no documentation in the medical record from 9/20/14 forward of the removal and disposal of the 9/19/14 patch.

During an interview of the Director of Risk Management on 6/12/15 at approximately 5:15 PM, she confirmed the findings.