HospitalInspections.org

Based on facility policy review, medical record review, and interviews, the facility failed to provide an ordered consultation timely for one patient (#2) of 6 patients reviewed.

The findings included:

Review of facility policy "Skin and Wound Care" last revised 3/2017, revealed "...A standard protocol involving interdisciplinary approach to skin care and prevention and treatment of wounds and pressure ulcers (injury) shall be adopted..."

Medical record review revealed Patient #2 was admitted to the facility on 5/19/18 for diagnosis including Dyspnea (shortness of breath), Pneumonia, End Stage Renal Disease, and Congestive Heart Failure.

Review of a physician's order dated 5/19/18 at 2:36 PM revealed "...CONSULTATION...wound care..." Further review revealed no documentation the wound care consultation was provided until 5/28/18 (9 days later).

Medical record review of a wound care progress note dated 5/28/18 at 6:20 PM revealed "...Buttocks/sacrum total area 11 cm [centimeters] X 10 cm several areas of partial thickness skin loss...this is related to moisture but pressure cannot be excluded..."

Interview with the Wound Care Nurse on 8/2/18 at 12:20 PM, in the Quality Assurance Conference Room, confirmed there was a physician's order for the wound care consultation for Patient #2 on 5/19/18 and the consultation was not provided until 5/28/18.

Interview with the Vice President of Quality and the Risk Manager on 8/2/18 at 2:20 PM, in the Quality Assurance Conference Room, confirmed there was no documentation the wound care consultation was provided prior to 5/28/18. Further interview confirmed wound care nurses were on-call and available on 5/19/18. Continued interview revealed the patient was not provided a wound care consult timely as ordered by the physician.