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MILFORD REGIONAL MEDICAL CENTER
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on interviews and documentation review the Hospital failed to ensure that treatment documentation was accurate and/or completed for one of one patients (Patient #1)
Findings included:
Medical record documentation, dated 9/11/10, indicated that Patient #1 presented to the Emergency Department (ED) with a swollen 2nd toe on the right foot that had been going on for weeks and was recently accompanied by fever and chills.
The ED Nurse assigned to Patient #1 was interviewed on 9/28/10 at 11:15 A.M. The ED Nurse said Patient #1 had a dressing on his/her right foot which the ED Nurse removed. The ED Nurse said after the ED Physician examined Patient #1's feet the ED Nurse cleansed the affected areas on the right foot with gauze soaked normal saline and applied a dry dressing.
Review of ED documentation by the ED Nurse indicated that the wound care/dressing was not documented.
Review of Physician Orders, dated/timed 9/11/10 at 11:56 P.M., indicated that a treatment was ordered for the wound which consisted of daily normal saline irrigation with a dry sterile dressing.
The nurse who admitted Patient #1 (Nurse #3) was interviewed in person on 9/28/10 at 8:25 A.M. Nurse #3 said when Patient #1 came to the Unit his/her right foot was covered with a clean dressing which she left intact.
Review of Nurse #3's documentation, dated 9/12/10, indicated that the right foot was left open to air.
The nurse assigned to Patient #1 on 9/12/10 during the 7:00 A.M. to 3:00 P.M. shift (Nurse #4) was interviewed on 9/28/10 at 8:30 A.M. Nurse #4 reported changing Patient #1's right foot dressing during the morning. Nurse #4 said prior to applying a clean dressing the affected area was cleansed with normal saline. Nurse #4 said the dressing was removed when Patient #1 went for a magnetic resonance imaging study of the right foot.
Review of treatment documentation from 7:00 A.M. to 3:00 P.M. on 9/12/10 indicated that the treatment performed by Nurse #4 was not documented.
Review of medical record documentation, dated 9/13/10, indicated that an Orthopedic Consult was performed. Patient #1's feet were examined by the Orthopedic Physician Assistant (PA). The PA documented a bedside debridement was performed.
The Orthopedic Physician Assistant (PA) was interviewed in person on 9/28/10 at 7:45 A.M. The PA said that on 9/13/10 he/she saw Patient #1. The PA said the documentation was erroneous because he/she did not perform a bed side debridement but rather cleansed and examined the wounds on the right foot by probing the wounds with Q-tips to determine the extent/depth of the wounds. The PA said initially a bedside debridement was considered however; after the examination the determination was made to schedule a surgical debridement.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on interviews and documentation review the Hospital failed to ensure that treatment documentation was accurate and/or completed for one of one patients (Patient #1)
Findings included:
Medical record documentation, dated 9/11/10, indicated that Patient #1 presented to the Emergency Department (ED) with a swollen 2nd toe on the right foot that had been going on for weeks and was recently accompanied by fever and chills.
The ED Nurse assigned to Patient #1 was interviewed on 9/28/10 at 11:15 A.M. The ED Nurse said Patient #1 had a dressing on his/her right foot which the ED Nurse removed. The ED Nurse said after the ED Physician examined Patient #1's feet the ED Nurse cleansed the affected areas on the right foot with gauze soaked normal saline and applied a dry dressing.
Review of ED documentation by the ED Nurse indicated that the wound care/dressing was not documented.
Review of Physician Orders, dated/timed 9/11/10 at 11:56 P.M., indicated that a treatment was ordered for the wound which consisted of daily normal saline irrigation with a dry sterile dressing.
The nurse who admitted Patient #1 (Nurse #3) was interviewed in person on 9/28/10 at 8:25 A.M. Nurse #3 said when Patient #1 came to the Unit his/her right foot was covered with a clean dressing which she left intact.
Review of Nurse #3's documentation, dated 9/12/10, indicated that the right foot was left open to air.
The nurse assigned to Patient #1 on 9/12/10 during the 7:00 A.M. to 3:00 P.M. shift (Nurse #4) was interviewed on 9/28/10 at 8:30 A.M. Nurse #4 reported changing Patient #1's right foot dressing during the morning. Nurse #4 said prior to applying a clean dressing the affected area was cleansed with normal saline. Nurse #4 said the dressing was removed when Patient #1 went for a magnetic resonance imaging study of the right foot.
Review of treatment documentation from 7:00 A.M. to 3:00 P.M. on 9/12/10 indicated that the treatment performed by Nurse #4 was not documented.
Review of medical record documentation, dated 9/13/10, indicated that an Orthopedic Consult was performed. Patient #1's feet were examined by the Orthopedic Physician Assistant (PA). The PA documented a bedside debridement was performed.
The Orthopedic Physician Assistant (PA) was interviewed in person on 9/28/10 at 7:45 A.M. The PA said that on 9/13/10 he/she saw Patient #1. The PA said the documentation was erroneous because he/she did not perform a bed side debridement but rather cleansed and examined the wounds on the right foot by probing the wounds with Q-tips to determine the extent/depth of the wounds. The PA said initially a bedside debridement was considered however; after the examination the determination was made to schedule a surgical debridement.