HospitalInspections.org
Bringing transparency to federal inspections
UNIVERSITY HOSPITALS PORTAGE MEDICAL CENTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
21893
29377
31007
31597
REMAINS CITED
Based on medical record review, policy review and interview, the facility failed to ensure nursing staff performed wound care as ordered for two of two patients with wounds out of a total of 13 medical records reviewed. (Patient #13 and #12)
Findings include:
1. The medical record review revealed a physician ordered daily wound care to Patient #13's left heel on 5/6/14 at 8:10 PM. The order stated to apply Santyl (a sterile enzymatic debriding ointment) to the center of the heel and hydrogel to the outside daily. The medical record lacked evidence any wound care was completed on 5/7/14.
2. The medical record review for Patient #12 revealed on 5/9/14 at 9:40 AM, a registered nurse documented Patient #12's left thigh abrasion was cleansed with soap and water and a Duoderm (a hydrocolloid dressing) was applied. The medical record lacked an order for this wound care to Patient #12's left thigh.
On 5/9/14 at 2:30 PM, these findings were confirmed with Staff A.
On 5/9/14 at 3:10 PM, the facility's Wound and Dressing Care policy was reviewed. The policy stated wound care and dressing changes require a physician order.