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6847 N CHESTNUT

RAVENNA, OH 44266

NURSING SERVICES

Tag No.: A0385

31007

Remains Cited.

Based on medical record review, staff interview, and policy review the facility failed to ensure nursing staff had orders prior to initiating wound care (A395); and failed to ensure the nursing care plan was updated to reflect and address all of patient's needs (A396). The cumulative affect of these systemic practices resulted in the facility's inability to ensure the patients' needs would be met. This affected two of the three patients with wounds or surgical incisions. The facility census at the time of the survey was 102.

Findings include:

The facility failed to ensure nursing staff had orders prior to initiating wound care. Please see A395.

The facility failed to ensure the nursing care plan was updated to reflect and address all of patient's needs. Please see A396.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

This is a Recite.

Based on medical record review, staff interviews, and review of policy, the facility failed to follow their plan of correction to ensure nursing staff had orders prior to initiating wound care for 1 of 1 sampled patients identified with a pressure sore (Patient #13). The census on the first survey day was 102 patients.

Findings include:

The medical record for Patient #13 was reviewed on 04/10/14. Patient #13 was admitted on 04/08/14. The admitting note by nursing staff revealed the patient was at risk for skin breakdown. The medical record documented Patient #13 had surgery to repair a fractured left hip.

A nursing note dated 04/05/14 at 3:17 PM revealed staff discovered a Stage II (open) area on Patient #13's left buttock, and a Stage I (reddened) area on Patient #13's right buttock. The left buttock pressure sore was cleansed with normal saline, and a dressing (Duoderm) was applied to the left buttock. The medical record documented the Duoderm dressing was in use from 04/05/15 through survey date of 04/10/14. Observation of Patient #13 on 04/10/14 at 1:50 PM revealed Patient #13's left buttock pressure sore was covered with the Duoderm dressing, and a reddened area was observed on Patient #13's right buttock. This observation was confirmed with nursing Staff F and H at 1:50 PM on 04/10/14.

A review of Patient #13's plan of care was conducted on 04/10/14 at 11:00 AM with Staff B and G. The plan of care was silent to the aforementioned pressure sore treatment.






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NURSING CARE PLAN

Tag No.: A0396

Remains cited.

Based on medical record view, and staff interview the facility failed to ensure the nursing care plan was updated to reflect and address all of patient's needs. This affected two (Patient #12 and #13) three patient medical records with a wound or surgical incision. The facility census at the time of the survey was 102.

Findings include:

1. The medical record for Patient #13 was reviewed on 04/10/14. The patient was admitted on 04/08/14. The admitting note by nursing staff revealed the patient was at risk for skin breakdown. The medical record documented this patient had surgery to repair a fractured left hip.

A nursing note dated 04/05/14 at 3:17 PM revealed staff discovered a Stage II (open) area on Patient #13's left buttock, and a Stage I (reddened) area on Patient #13's right buttock. The left buttock pressure sore was cleansed with normal saline, and a dressing (Duoderm) was applied to the left buttock. The medical record documented the Duoderm dressing was in use from 04/05/14 through survey date of 04/10/14. Observation of Patient #13 on 04/10/14 at 1:50 PM revealed Patient #13's left buttock pressure sore was covered with the Duoderm dressing, and a reddened area was observed on Patient #13's right buttock. This observation was confirmed with nursing Staff F and H at 1:50 PM on 04/10/14.

A review of Patient #13's medical was conducted on 04/10/14 at 11:00 AM with Staff B and G. Nursing documentation revealed the Duoderm dressing was initiated on 04/05/14 at 3:17 PM and was used as a treatment on Patient #13's pressure sore through the survey date of 04/10/14. The medical record was silent to a physician's order for the pressure sore treatment. Staff B stated the facility policy for Duoderm use on a pressure sore required a physician's order. Staff B and G confirmed the lack of a physician's order for Patient #13's pressure sore treatment.

2. The medical record for Patient #12 was reviewed on 04/10/14 with Staff B and G. Patient #12 was admitted on 04/08/14 with a diagnosis of ruptured spleen. Patient #12 received surgical services on 04/08/14 for removal of their spleen. According to the surgeon's operative note, a suture was placed along with skin staples at the midline abdominal incision. A physician's order dated 04/08/14 at 5:20 PM stated reinforce surgical dressing as necessary and change dressing daily starting 24 hours post operatively.

The plan of care was silent to interventions for the abdominal incision and to the dressing change. This was confirmed with Staff B and G during the medical record review.








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