HospitalInspections.org

Based on a review of policies and procedures, medical records and interviews, it was determined the facility did not adhere to the facility's policies and procedures for wound care for one of one patient (Patient #27 ) which has the potential health risk to patient's wound care not be assessed and treated.

Findings include:

Review of the hospital policy titled "Skin Integrity: Prevention and Early Intervention for Skin Breakdown" dated 6/11/2014 revealed: "...Patient's wounds area assessed and documented on admission, when wound is identified and at time of treatment. Presence of a wound should be noted if observed when admitted from ancillary, procedural or emergency services. Once admitted, patient wounds are documented and described in detail using the categories of partial or full thickness wounds, deep tissue injury and unable to determine...Wound measurements are done on admission or wound discovery, weekly and or at dressing change...Pressure ulcers are staged by Wound Ostomy Continence Nurses, Certified Wound Specialist, Physical Therapy, wound care specialists or designee, and physicians...All dressings will be changed using appropriate precautions...."

Review of Patient #27 's medical record revealed that Patient # 27 was admitted on 7/21/15, and discharged on 7/24/15. Patient #27 had the following wounds: left posterior shoulder,
right shoulder, back posterior left, sacrum, left posterior heel, right posterior heel, and right medial foot. The only documentation of the wounds were "stable."

RN Manager # 2 confirmed in an interview conducted on 9/2/15 at 1530, that there was no other documentation for the surveyor review except for the location of the seven wounds and that the wounds were stable. She also confirmed that there was no documentation for review of the type of wounds, the type of dressings ordered or when the dressings were changed; and that the facility did not follow their policy on wound care.

Based on a review of policies and procedures, medical records and interviews, it was determined the facility did not adhere to the facility's policies and procedures for Swing Bed Program Activities for one of one patient, (Patient #30) which has the potential risk to the physical, psychosocial and intellectual well-being of each swing bed patient.

Findings include:

Review of the hospital policy titled " Swing bed Program: Activities " dated 4/4/2014 revealed: " ...To provide a program of activities of interest to promote the physical, psychosocial and intellectual well-being of each swing bed patient. Activities will be the responsibility of all staff...An ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each swing bed patient...from the activities care plan, the staff will direct the activities for the patient and will evaluate the effectiveness of the care plan...Activities in which the patient took part will be documented daily.... "

Review of Patient # 30's medical record revealed that Patient # 30 was admitted on 9/5/14, with right and left hip repairs from another healthcare facility. Patient # 30 was admitted to the Swing Beds on 9/5/14, and was re-admitted to Inpatient on 9/14/14.

RN #18 confirmed in an interview conducted on 9/2/15, that there was no documentation for the surveyor review of Patient # 30's activities. She also confirmed that the facility did not follow their policy on Swing Bed Activities.

RN Manager # 2 confirmed in an interview conducted on 9/3/15, that there was no documentation for the surveyor review of Patient # 30's activities. She also confirmed that the facility did not follow their policy on Swing Bed Activities.