HospitalInspections.org

.
Based on Medical Record review and interview in two (2) of ten (10) records reviewed, the Nursing Staff did not consistently document wound care.

Findings:

Review of Patient #4's Medical Record revealed that the patient was admitted to the hospital on 01/27/16 for cardiac arrest. During his stay at the facility the patient had critical lab levels including an elevated INR and decreased albumin levels and required intubation with ventilation, trach placement and G-Tube placement. The patient was eventually transferred to a tertiary hospital on 05/11/16 due to his declining condition.

Review of the patient's Wound Care Orders identified an Order on 03/22/16 for daily wound care to the sacrum to be done daily. There was no documented evidence treatment was performed on 03/24, 03/26, 03/27 and 03/28.

Similar findings were noted on twelve (12) other days between 04/01/16 - 05/11/16.

These findings were confirmed with Staff B, Performance Improvement Coordinator, at the time of the review.

Review of Patient #2's Medical Record revealed that the patient was brought to the hospital on 03/08/16 for a Fever. The patient had a medical history of End Stage Renal Disease requiring Hemodialysis, Insulin Dependent Diabetes, Peripheral Vascular Disease, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension and a Right Leg Amputation in October of 2015.

The patient was admitted with Sepsis and wounds to the left foot, which required an above knee amputation on 04/05/16.

Review of the patient's Wound Care Orders identified an Order on 06/22/16 for wound care to the sacrum to be done daily. There was no documented evidence treatment was performed on 07/07, 07/08, 07/09 and 07/10.

These findings were confirmed with Staff B, Performance Improvement Coordinator, at the time of the review.