HospitalInspections.org

Based on review of one of two clinical records as part of a complaint investigation there was a failure to supervise and evaluate patient care by failing to apply bandages and administer medications as ordered and failing to turn the patient as ordered.
Findings:

Citing patient #2 an 87 year old female, was admitted to the facility on 1/3/2011 for treatment of recent paranoia and mood swings.
The admission physical examination reflected : Skin: normal, no wounds, rashes, cuts. Gait: abnormal. Severe deformity of her knees.
Admission nursing assessment. Skin: no lacerations,scars,bruises, rash . No pressure sores.
Progress notes reflected the patient was wheelchair and bed bound.

On 1/7/2011 physician #57 noted: "Patient developing sores. talked with director of nursing and unit nurse as well to prevent these sores from getting worse she will need special care."

On 1/7/2011 physician #56 (Internal Medicine) noted the following:
"Asked to evaluate bed sore. 1.5cm x 2.5cm sacral decubiti wound.
Order: Turn patient every 2 hours; Duoderm Patch to sacral wound every 72 hours."

1/15/2011 1310hrs. Order: Xenaderm Cream to bottom daily."

Review of the Medication Administration Record (MAR) reflected that although Duoderm Patch was ordered on 1/7/2011, Duoderm was not applied until 1/18/2011, 12 days after ordered.

The MAR reflected that although Xenaderm Cream was ordered on 1/15/2011, Xenaderm was not applied until 1/19/2011, 4 days after ordered.


Review of the Special Observation Record reflected the following:

1/8/2011
From 1:45 am - 5:45 am the patient was on her left side. Four hours elapsed before the patient was turned.

From 2:45pm - 5:15 pm the patient was on her back. 2 1/2 hours elapsed before the patient was turned.


1/10/2011
There was no special observation record for this date

1/12/2011
From 1200 am - 7:00 am the patient was on her back. She was not turned until 7 hours had elapsed.

From 9:00pm through 11:45 pm the patient was noted to be in bed. However, the position of the patient was not noted,

1/13/2011
From 12:00am - 3:00am the patient was on her right side. The patient was not turned until 3 hours had elapsed.

From 8:45pm to 11:45pm the patient was on her right side. The patient was not turned until 3 hours had elapsed.

1/14/2011
From 12:00am - 4:30am the patient was on her back. the patient was not turned until 4 1/2 had elapsed.

from 7:00pm - 10:30pm it was noted the patient was in bed. The position of the patient was not noted The patient was not turned until 3 1/2 hours had elapsed.

1/15/2011
From 3:15am - 5:45am the position of the patient was not noted. However, 2 1/2 hours elapsed before the patient was turned.

1/17/2011
From 3:15am - 5:45am the patient was on her left side. She was not turned until 2 1/2 hours elapsed.



1/17/2011 5:00pm Physicians Order
TURN PATIENT EVERY ONE HOUR

Review of the Special Observation Record reflected the following:

1/18/2011
From 1:15am - 3:15am the patient was on her left side. She was not turned until 2 hours had elapsed.

From 5:15am - 7:00am the patient was noted to be in bed with no position identified. She was not turned until 1 hour 45 minutes had elapsed.

From 7:15pm - 8:45pm there was no record of the patients position. She was not turned until 1 1/2 hours had elapsed.

1/19/2011
From 11:15pm (1/18/11) - 2:25am (1/19/11) the patient was on her back. She was not turned until 3 hours had elapsed.

From 2:20am - 5:30am the patient was on her left side. The patient was not turned until 3 hours had elapsed.

1/20/2011
From 11:15pm (1/19/11) - 1:45am (1/20/11) the patient was on her right side. She was not turned until
2 1/2 hours had elapsed.

From 2:00am - 5:45am the patient was on her back. The patient was not turned until 3 hours 45 minutes had elapsed


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