HospitalInspections.org

Based on clinical record review, policy and procedure review and interview, it was determined the facility staff failed to assure a physician order was obtained for the treatment of a decubitus for one of one (Patient #1) inpatient ICU (Intensive Care Unit) patient with acquired decubitus and one closed patient record (Patient #11). The failed practice affected the one open and one closed record (Patient #1 and Patient #11, and had the potential to affect all 16 patients admitted to the ICU. The findings are:

A. Clinical records review on 06/03/11 at 1350 revealed Nurses notes- Patient #1 had a Stage II decubitus to his buttocks, identified by staff 05/30/11 Nurses notes documentation "Stage 2 Decub noted to coccyx. DuoDerm on". Review of physician orders and progress notes did not include physician order for DuoDerm. On 06/02/11 at 2200, a nursing note revealed, "Mepilex 10 cm x 10 cm placed to pt. coccyx wound." Review of physician orders and progress notes did not include physician order for Mepilex.
B. Interview with R.N. (Registered Nurse) assigned to care for the patient 06/03/11 at 1530, she stated the treatment for the stage II decubitus was "clean with wound spray and cover with Mepilex." Asked how she would know to provide the treatment, she stated "Because that's what it has on it." Clinical record review revealed there was no physician order for the treatment of the wound.
C. In an interview with the Pharmacy Director, she stated "SAF Cleanse AF" was the product used. Review of product label with the Pharmacy Director 06/03/11 at 1450 revealed the statement "Federal Law Prohibits sale except by or on the order of a physician."
D. Facility Policy # IIC-3 stated, "Patients who have skin breakdown or have lower than 18 score on Braden scale will be referred to the Wound Care Nurse on admission or anytime the score becomes 18 or below or when breakdown is noted. After assessment is made by Wound Care Nurse and physician orders received, the Wound Care Nurse will initiate the care." Braden score of 13 was documented on the ICU shift assessment on 05/31/11 at 0700 and 1947.
E. Closed record review for Patient #11 revealed the patient was admitted on 03/29/11 at 1220 to the Intensive Care Unit. Documentation on 03/31/11 at 0530 stated, "Patient repositioned up and onto right side supported with pillows for complaints of buttocks being sore, denies further needs...". Nurses notes on 03/31/11 at 1752 stated, "Complete bed bath given, linens changed. Red Area to buttock, Duoderm to site." Review of physician order revealed no order for the use of Duoderm.
F. The findings were confirmed by interview with the RN, Director of Intensive Care Unit on 06/03/11 at 1445, she stated "I would expect to see an order from the physician for decubitus treatment orders."