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DESERT VALLEY HOSPITAL
No Description Available
Tag No.: A0404
Based on observation, interview and record review, the facility the failed to follow a physicians order when Patient 1's wound care was not carried out as prescribed. This had the potential for Patient 1's wound to become infected.
Findings:
On November 7, 2011 at 1:26 PM, Patient 1 was observed in his room under contact isolation for MRSA and VRE (strong antibiotic resistant infections to his abdomen and arm). Patient 1 was observed with a partially scabbed over pressure ulcer to the bridge of his nose. There was no dressing on Patient 1's wound.
The clinicalrecord for Patient 1 was reviewed on 11/7/11. The document titled "WOUND/SKIN CARE PHYSICIANS ORDERS" dated 10/24/11, indicated,"STAGE III ULCER OR FULL THICKNESS: Location(s): nose bridge, 1. Cleanse with NS (normal saline), Wound Cleanser 2. Apply: Santyl 3. Cover with: Foam Dressing and medipore tape 4. Change: Daily." The intervention in Patient 1's care plan revealed, "Dressing change to wound on bridge of nose to be done daily/PRN by bedside nurse: Clean with NS, pat dry with sterile gauze. Apply Santyl to wound bed over black eschar scab. Cover with foam dressing and medipore tape."
During an interview with the bed side nurse for Patient 1 she stated, "I cleansed with NS patted it dry then applied Santyl and left open to air."
CONTENT OF RECORD: STANDING ORDERS
Tag No.: A0457
Based on interview, and record review, the facility failed to ensure the physicians telephone order was signed within 48 hours. This resulted in Patient 1's treatment not to be carried out as ordered.
Findings:
The clinical record for Patient 1 was reviewed on 11/7/11. The T/O (Telephone Order) for Patient 1's pressure ulcer to the bridge of the nose was signed and dated 10/24/11 at 1630 (4:30 PM), by the nurse. During the record review it was noted that the T/O had not been signed by Patient 1's physician.
The document titled "Desert Valley Hospital General Rules and Regulations" indicated, "3. 1-2 Verbal orders (T/O) shall be written on the Physicians Order Sheet and signed by the person to whom dictated and shall be followed by the name of the practitioner dictating the order and shall be authenticated by the practitioner within forty-eight hours."
During an interview with the director of nurses on 11/7/11, she stated, "He should have signed the orders within 48 hours according to our bylaws."