HospitalInspections.org

Based on review of policies and procedures, medical record, and interview with staff, it was determined that the hospital failed to require a registered nurse supervise and evaluate the nursing care for 1 of 1 patients requiring wound dressing changes (patient # 1), as ordered. This deficient practice poses the potential risk that necessary care was not provided according to physician orders as evidenced by no documentation in the medical record of 19 of 52 dressing changes being conducted.

Findings include:

Policy titled "Wound Dressing Change/Applications" revealed: "...1. Wound Care order and Treatment records will be located in the patient's chart, located under the wound care tab. One sheet will be used per order, per treatment...11. Apply physician ordered wound medication, ointment, and/or primary dressing...18. Document condition of wound on the treatment record...."

The medical record review revealed the following:

Physician Wound Care Order on 08/26/2020 at 0800 revealed: "...Clean with soap/water. Apply Santyl. Cover with dry dressing. Change daily...."

MD #2 Consultation dated 8/26/2020 at 13:07 revealed: "...Clean wound with wound cleanser. Apply Santyl to the open wounds and cover with ABD. Change dressings daily...The Pt may require excisional debridement...."

Wound Care Treatment Record revealed that wound care was documented daily from 08/26/2020 to 09/01/2020.

MD #2 Physician Progress Notes dated 9/1/2020 at 09:16 revealed: "...Continue Santyl dressings. Cover with ABD. Change dressings daily...."

Wound Care Treatment Record revealed that wound care WAS NOT documented on 09/02/2020 and 09/03/2020.

MD #2 Physician Progress Notes dated 9/3/2020 at 09:43 revealed: "...Clean wound with wound cleanser. Apply Santyl dressings to the open wound. Cover with gauze and ABD. Change dressings daily...."

Wound Care Treatment Record revealed that wound care was documented daily from 09/04/2020 to 09/07/2020.

MD #2 Physician Progress Notes dated 9/7/2020 at 10:14 revealed: "...Bilateral buttock wounds have dense necrotic tissue on the wound bed occupying more than 85% of the wound bed. There is no purulent drainage or exudate. Periwound denudement is slightly improved...Clean wounds with wound cleanser. Continue Santyl dressings. Cover with gauze and ABD. Change dressings daily...We will plan for possible excisional debridement...."

MD #2 Physician Progress Notes dated 9/8/2020 at 07:56 revealed: "...Continue Santyl dressings. We will plan for excisional debridement if we can obtain consent from the patient's power of attorney or family members...."

Physician Wound Care Order dated 09/08/2020, signed 09/09/2020 at 0800 revealed: "...Clean with wound cleanser. Apply 1/2...Dakins soaked gauze. Cover with dry dressing...Change BID...."

Wound Care Treatment Record revealed that wound care was documented 09/08/2020 A.M. shift; wound care WAS NOT documented 09/08/2020 P.M. shift.

Consent for Wound Debridement dated 9/8/2020, phone consent with MPOA [Shannon Duvall, Daughter].

MD #2 Physician Progress Notes dated 9/9/2020 at 14:49 revealed: "...Periwound erythematous denudement appears to be significantly improved...Excisional debridement of the wound was done at the bedside using size #10 blade and forceps to remove necrotic tissue...We will change dressings to half-strength Dakin's solution moistened gauze. Cover with ABD. Change dressings daily for now...."

MD #2 Physician Progress Notes dated 9/10/2020 at 08:15 revealed: "...[Sacrococcygeal and buttock] wounds have improved significantly compared to previous evaluations. There is still some slough at the wound bed...Periwound maceration is improved...Clean wound with wound cleanser. Apply half-strength Dakin's solution moistened gauze to the wound bed. Cover with ABD. Change dressings daily...."

Wound Care Treatment Record revealed that wound care was documented 09/09/2020, 09/10/2020, 09/11/20 and 09/12/2020 A.M. shift; wound care WAS NOT documented 09/09/2020, 09/10/2020, 09/11/2020 and 09/12/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/12/2020 at 08:38 revealed: "...Clean wound with wound cleanser. Apply quarter-strength Dakin's solution moistened gauze and cover with ABD. Change dressings daily...."

NO NEW PHYSICIAN ORDERS WRITTEN

Wound Care Treatment Record revealed that wound care was documented 09/13/2020 A.M. shift and 09/13/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/14/2020 at 08:26 revealed: "...[Sacrococcygeal and adjacent buttocks] wounds still have some nonviable fibrofatty tissue on the wound bed. There is no purulent drainage or exudate. There is some deep tissue injury on the wound margins...Change dressings BID...The patient will require more extensive surgical wound debridement in the OR...."

Wound Care Treatment Record revealed that wound care WAS NOT documented 09/14/2020 and 09/15/2020, both A.M and P.M. shifts.

MD # 2 Physician Progress Notes dated 9/16/2020 at 09:07 revealed: "...Bilateral [sacrococcygeal and buttock] wound still has some dense necrotic slough at the wound bed. There is no purulent drainage or exudate. Periwound areas of excoriations are slightly improved...Continue saline-moistened gauze dressings cover with ABD. Change dressings daily...Discontinue half-strength Dakin's solution moistened gauze dressings. The patient needs for further surgical debridement in the OR...."

NO PHYSICIAN ORDERS WRITTEN

Wound Care Treatment Record revealed that wound care was documented 09/16/2020 P.M. shift; wound care WAS NOT documented 09/16/2020 A.M. shift.

MD #2 Physician Progress Notes dated 9/17/2020 at 12:11 revealed: "...The patient was admitted to this facility with very complex [sacrococcygeal and buttock] unstageable pressure injuries which were completely necrotic. An initial debridement was done to decrease the bacterial bioburden and prevent worsening infection. We are currently doing saline moistened gauze dressings to the wound bed. The patient will however require more extensive debridement in the OR when he is more medically stable...[sacrococcygeal and adjacent buttock] wounds still have some fibrofatty nonviable tissue at the wound bed. However, there is no purulent drainage or exudate and no sign of active wound sepsis at this time...We will plan for subsequent excisional extensive debridement in the OR. This will have to be done by general surgeon. The patient will be referred for subsequent wound debridement when he is more clinically stable after discharge from this facility...."

Wound Care Treatment Record revealed that wound care was documented 09/17/2020 A.M. shift; wound care WAS NOT documented 09/17/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/18/2020 at 07:45 revealed: "...Complex [sacrococcygeal] open wound appears to be fairly clean but still have some bands of nonviable adherent tissue at the wound bed...There is no purulent drainage or exudate. There is no odor. There is no sign of active wound infection. Periwound excoriations appear to be improving...Continue with saline moistened gauze and ABD dressings BID to the wound bed...The patient will require a more extensive excisional debridement in the OR when more clinically stable. Our short-term wound care goal is to keep this wound clean...."

Wound Care Treatment Record revealed that wound care was documented 09/18/2020 P.M. shift; wound care WAS NOT documented 09/18/2020 A.M. shift.

Wound Care Treatment Record revealed that wound care was documented 09/19/2020 P.M. shift; wound care WAS NOT documented 09/19/2020 A.M. shift.

Wound Care Treatment Record revealed that wound care was documented 09/20/2020 A.M. shift and 09/20/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/21/2020 at 08:05 revealed: "...[Sacrococcygeal] wound still has some dense necrotic slough on the wound bed...There is no purulent drainage...Periwound excoriations are slightly improved...Change dressings BID. We will plan for further excisional debridement in the OR when the patient is more clinically stable...

Wound Care Treatment Record revealed that wound care was documented 09/21/2020 P.M. shift; wound care WAS NOT documented 09/21/2020 A.M. shift.

MD #2 Physician Progress Notes dated 9/22/2020 at 07:39 revealed: "...[Sacrococcygeal and adjacent buttock] wound still have some dense fibrofatty tissue at the wound bed. There is no purulent drainage or exudate. Periwound areas of excoriations appear to be improved...Clean wound with wound cleanser. Apply saline-moistened gauze and cover with ABD. Change dressings b.i.d...The patient needs more extensive excisional debridement...."

Wound Care Treatment Record revealed that wound care was documented 09/22/2020 A.M. shift and 09/22/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/23/2020 at 08:29 revealed: "...The patient was seen and fully evaluated for followup of complex wound care issues...reviewed with nursing staff...previous wound care plan and wound care instructions were reviewed with Nursing...[Sacrococcygeal] wound has dense necrotic fibrofatty tissue at the wound bed. There is no purulent drainage or exudate. Periwound areas of excoriations appear to be significantly improved...I sent the patient's wound pictures and referral to [Dr. ___] for a more extensive debridement in the OR beyond what we can do at the bedside here...Wound team will continue to follow and monitor closely...."

Physician Wound Care Order dated 09/23/2020 at 0900 revealed: "...Clean with soap water, Apply W/D. Saline to wound. Change BID...."

Wound Care Treatment Record revealed that wound care was documented 09/23/2020 A.M. shift and 09/23/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/24/2020 at 09:37 revealed: "...The patient was seen and fully evaluated for followup of complex wound care issues. Previous wound care plan and wound instructions were reviewed with nursing staff. Case was also discussed with [Dr. Jacobsen]...[sacrococcygeal]...open wounds appear to be unchanged in size. There is still some necrotic tissue at the wound bed. There is no purulent drainage or exudate...Case was discussed with [Dr. Jacobsen]. We will plan for excisional debridement of complex wound in the OR by [Dr. Jacobsen]...Case was also discussed with nursing and case management. The patient can be discharged to [Montecito] after extensive debridement by [Dr. Jacobsen] directly...."

MD #1 Physician Progress Notes dated 9/24/2020 at 16:41 revealed: "...Continue with aggressive wound care...The patient will need debridement of the [sacral decubitus ulcer] to be done at the OR...Plan is for transfer the patient to [St. Joseph Hospital] for the wound to be debrided by [Dr. Jacobson]...This has been arranged by the wound care team here...."

Wound Care Treatment Record revealed that wound care was documented 09/24/2020 A.M. shift and 09/24/2020 P.M. shift.

MD #2 Physician Progress Notes dated 9/25/2020 at 09:21 revealed: "...The patient was seen and fully evaluated for followup of complex wound care issues. Previous wound care plan and wound instructions were reviewed with nursing staff...[Sacrococcygeal wound] has dense necrotic tissue covering over 75% to 80% of the wound bed. There is no purulent drainage or exudate. Periwound skin is intact...Clean wounds with wound cleanser. Apply saline-moistened gauze packing and cover with ABD. Change dressings b.i.d...Plan for extensive debridement of wound in the OR by [Dr. Jacobsen] at [St. Joseph's Hospital]. Case was discussed with MD #1...."

MD #1 Physician Progress Notes dated 9/25/2020 at 16:42 revealed: "...The patient was unable to be transferred to [St. Joseph] yesterday secondary to bed inability...Plan is for transfer to [St. Joseph] for debridement by [Dr. Jacobson]...."

Wound Care Treatment Record revealed that wound care was documented 09/25/2020 A.M. shift; wound care WAS NOT documented 09/25/2020 P.M. shift.

Wound Care Treatment Record revealed that wound care was documented 09/26/2020 A.M. shift; wound care WAS NOT documented 09/26/2020 P.M. shift.

MD #1 Physician Progress Notes dated 9/27/2020 at 15:04 revealed: "...The patient has a [sacral decubitus] which needs debridement, plan is for transfer to [St Joseph's] for wound debridement by [Dr. Jacobsen]...."

Wound Care Treatment Record revealed that wound care was documented 09/27/2020 A.M. shift. The patient was transferred to [St. Joseph Hospital] for surgical debridement in an OR.

Employee #1 revealed during interview on 11/18/2020 at 1330 that the wound care nurses conduct the dressing changes in the A.M. shift, 7 days/week. The night shift RN's conduct the NOC (night) dressing changes during the 7 p-7 a shift. Employee #1 relayed that the RN's do not refer to Physician Progress Notes to detect changes for orders. Employee #1 acknowledged that Physician Wound Care Orders are documented in a separate area of the medical record, away from the standard Physician Orders, and that staff must check in two separate areas of the patient medical record to note orders. Employee #1 acknowledged during interview that there were 19 wound care treatments that were not documented.