HospitalInspections.org

Based on clinical record review and staff interview, the facility failed to ensure that the nurses consistently performed the prescribed nursing treatments for wound care for 1 of 3 (Patient # 2) patients who was reviewed for pressure ulcers.

The findings included:

The clinical record for Patient #2 disclosed that the patient was admitted to the facility on 03/08/17 and the initial assessment identified wound issues on her right shoulder. The physician prescribed treatment included, "To cleanse the area with normal saline and apply Mediplex border lite every 2 to 3 days and as needed." Further review of the clinical record failed to provide evidence the nurses performed the prescribed wound care on 03/11/17 and on 03/21/17.

Furthermore, on 03/16/17 the physician prescribed treatment included, "To paint the right humeral wound with Betadine twice daily and cover with a dry dressing." The facility failed to provide evidence that the nurses performed the prescribed twice-daily treatment on 03/19/17 and 03/20/17.

An interview and clinical record review was conducted with the Wound Care Nurse on 05/05/17 at approximately 3:45 PM. She confirmed she was unable to locate documentation that the nurses performed the prescribed treatments.