HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure the registered nurse supervised nursing care and services for assessments and wound care for two (#2, #5) of 10 sampled patients.

Findings included:

1. Patient #5 was admitted on 12/24/15 with diagnoses that included an acute urinary tract infection.

Review of the Vital Signs flow sheet revealed Patient #5 did not have his temperature monitored between 1/5/16 at 7:15 a.m. and 1/8/16 at 3:00 a.m. when the temperature was recorded at 89 degrees Fahrenheit rectally.

The findings were confirmed on 4/25/16 at approximately 2:30 p.m. by the Quality Improvement Coordinator at the time of the record review.

2. Patient #2 was admitted on 4/15/16 with diagnoses that included a large decubitus ulcer on the sacrum.

The Physician's Order dated 4/15/16 at 6:35 p.m. and signed by the attending physician instructed to cleanse the sacral wound with normal saline, apply aquacel ag and cover with coverdern or gauze once daily.

A detailed review of the medical record for Patient #2 failed to reveal any evidence of nursing reassessment of the wound following the Wound Care Consultation on 4/15/15, a period of 10 days. There was no evidence of wound care being performed in accordance with the physician ordered plan of treatment on 4/20/16 through 4/25/16, a period of 5 days.

The findings were confirmed in an interview and record review conducted on 4/26/16 at 11:00 a.m. with the Registered Nurse assigned to the care of Patient #2 and the Quality Improvement Coordinator.