HospitalInspections.org

B. Based on document review and interview, it was determined for 2 of 3 patients with skin wounds (Pts. #2 & 3), the hospital failed to ensure nursing properly assessed skin wounds.

Findings include:

1. Hospital policy titled, "Pressure Ulcer Prevention and Treatment", effective 6/14/13, was reviewed on 8/4/14. The policy required, "F. Documentation of existing or developed pressure injury or lesion will include: location, size (length x width x depth) in cm., stage, appearance of wound bed..."

2. On 8/4/14 at 11:20 AM, Pt. #2's clinical record was reviewed. Pt. #2 was an 84 year old male, admitted on 8/2/14, with diagnoses of debility and generalized weakness. A nursing assessment dated 8/2/14 at 1:45 PM, included a stage II medial coccyx wound. However, there were no wound measurements. Subsequent assessments did not include medial coccyx measurements.

3. On 8/4/14 at 11:05 AM, Pt. #3's clinical record was reviewed. Pt. #3 was a 72 year old female, admitted on 7/27/14, with diagnoses of lung cancer and hypertension. Pt. #3's skin assessment on 7/28/14 at 12:24 AM, included a left elbow wound, but another skin assessment 6 minutes later, at 12:30 AM, included a right elbow abrasion. Subsequent assessments included an elbow abrasion, but still did not indicate left or right.

Pt. #3's elbow wound was no longer included in the skin assessment after 7/30/14 at 11:29 AM. It could not be determined if Pt. #3's elbow wound was healed. Pt. #3 is still on the Ortho unit on 8/4/14.

4. An interview was conducted on 8/4/14 at 11:25 AM, with the Ortho Nurse Manager (E #2). E #2 stated nursing should have measured Pt. #2's stage 2 coccyx wound for a baseline comparison. E #2 reviewed Pt. #3's medical record, but was unable to determine if the elbow wound was on the left or right elbow and if the wound was healed or not.




27125

A. Based on document review, stated practice and interview, it was determined for 1 of 1 (Pt. #1) patients transferred to CCU (cardiac care unit), the hospital failed to inform the family of a change in patient condition.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 8/4/14. Pt. #1 was a 72 year old male admitted on 6/13/13 with the diagnosis of pubic ramus (pelvic) fracture. The clinical record lacked documentation of Pt. #1's family being notified of a change in condition resulting in a transfer to CCU on 6/16/13.

2. The RN (E#4) caring for Pt. #1 when transferred to CCU was interviewed on 8/5/14 at 7:35 AM. E#4 does not recall calling the family; however, stated she should have.

3. The CCU RN (E#5) was interviewed on 8/5/14 at 8:30AM. E#5 stated, " When a patient is transferred to CCU because of becoming unstable, it is the units ' responsibility that is transferring the patient to call the family. "

4. During an interview on 8/5/14 at 10:05 AM, the Manager of Quality Resource Department stated, "someone from the staff should have contacted the family."