HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that the Medical Staff complied with the General-Medical Staff Rules and Regulations for the content of the History and Physicals (H&P) for 2 of 8 sampled patients (Patients 6 and 7) that had diabetic ulcers on admission. This failure may have contributed to the patients that received care and services in the hospital to not have all of their patient care needs met.

Findings:

On September 5, 2012, a review of the facility's General-Medical Staff Rules and Regulations indicated that the attending practitioner shall be responsible for a legible and timely medical record for each patient. Its contents shall be pertinent and current. This record shall include: identification data, chief complaint, history of present illness, past medical history, physical examination and appropriate contents.

1. On September 5, 2012, Patient 7's medical record was reviewed with the Wound Care Nurse (WCN).

A review of the face sheet showed that Patient 7 was admitted to the facility on September 3, 2012 with a diagnosis of urinary retention (the body is unable to rid itself of urine).

A review of the document Wound Assessment/Photographic Wound Documentation (WAPWD), dated September 3, 2012 at 5:17 PM, showed that the patient had two diabetic ulcers on the right foot, on the first (large toe) and second toe.

A review of the Nursing Assessment, dated September 3, 2012 at 5:10 PM, the patient received a topical wound care treatment on the right first toe.

A review of the History and Physical (H&P) for Patient 7, which was dictated on September 4, 2012, did not indicate that the patient had two diabetic ulcers on the right foot, first and second toe.

On September 5, 2012 at 10 AM, an interview was conducted with the WCN. She confirmed that the patient was admitted to the facility with two diabetic ulcers on the right foot, first and second toe. The WCN stated that the wounds should have been addressed in the patient's H&P.

2. On September 7, 2012, Patient 6's medical record was reviewed with the Wound Care Nurse.

A review of the face sheet showed that Patient 6 was admitted to the facility on July 18, 2012 with a diagnosis of left foot cellulitis (inflammation of connective tissue).

A review of the WAPWD document, dated July 19, 2012 at 5 AM, showed that the patient had a right foot plantar diabetic ulcer.

A review of the WAPWD document, dated July 19, 2012 at 5 AM, showed that the patient had a right lateral foot diabetic ulcer.

A review of the Wound/Skin Physician Orders (WSPO), dated July 19, 2012 at 5 AM, showed a telephone order (TO) for the patient's two right foot diabetic wounds. The order indicated to cleanse with wound cleanser, apply hydrogel and cover with a composite dressing.

A review of the History and Physical for Patient 6, dated July 19, 2012, indicated that the patient had left thigh swelling and redness. The H&P did not address the two right foot diabetic ulcers. The H &P was authenticated by the physician on July 27, 2012.

On September 7, 2012 at 9:40 AM, the WCN stated that the patient's H&P should have addressed the two right foot diabetic ulcers.

Based on interview and record review, the hospital failed to ensure that the Discharge Summaries for 3 of 8 sampled patients (Patients 2, 5 and 6) recapitulated the patients' altered skin integrity that required treatment during their hospital courses. The hospital failed to address the recommendations and arrangements for future care for 1 of 8 sampled patients (Patient 2). These deficient practices contributed to the increased risk of harm to the patients after their hospital stays due to the failure to maintain the continuance of future care for the patients.

Findings:

1. On September 7, 2012, Patient 2's medical record was reviewed with the facility's WCN.

A review of the face sheet showed that the patient was admitted on July 19, 2012 with an admitting diagnosis of a diabetic foot ulcer. The patient was discharged home on July 27, 2012.

A review of the WSCPO, dated July 19, 2012, showed a telephone order for wound care for the patient's diabetic ulcers to the right first toe, right inner fourth toe, and the left lateral foot. The PO indicated to monitor any change, keep clean and dry.

A review of the patient's medical record showed that on July 23, 2012 the patient underwent a right first toe debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).

A review of the patient's medical record showed that on July 24, 2012, the patient had a Groshong catheter (an intravenous catheter used for central venous access) placed in his left subclavian chest wall for intravenous antibiotic therapy.

A review of the physicians progress notes, dated July 25, 2012, indicated that the patient required a visiting home nurse to assist the patient with dressing changes and antibiotic administration.

A review of the physicians progress notes, dated July 26, 2012, indicated that the patient required a visiting home nurse to assist the patient with dressing changes and antibiotic administration through catheter (Groshong).

A review of the Discharge Summary that was dictated on July 31, 2012, and authenticated on August 5, 2012, showed that the discharge instructions included, "The patient was educated on diet, exercise, and to keep diabetes under control. The patient was also educated on keeping the dressing clean and intact and how to change the dressing." The documentation did not indicate that the patient required assistance from a home health service for dressing changes and/or intravenous antibiotic (IVABT) administration via the Groshong catheter that remained in the patient's left subclavian chest wall.

On September 7, 2012 at 11 AM, an interview was conducted with the WCN. She stated that she was familiar with the Patient 2's hospital course. The WCN confirmed that the patient required home health assistance for dressing changes and IVABT administration via the Groshong catheter upon discharge. She confirmed that the patient's discharge continuing care needs should have been included in the discharge summary documentation.

2. On September 7, 2012, Patient 6's medical record was reviewed with the Wound Care Nurse.

A review of the face sheet showed that Patient 6 was admitted to the facility on July 18, 2012 with a left foot cellulitis (inflammation of connective tissue) diagnosis.

A review of the WAPWD document, dated July 19, 2012 at 5 AM, showed that the patient had a right foot plantar diabetic ulcer.

A review of the WAPWD document, dated July 19, 2012 at 5 AM, showed that the patient had a right lateral foot diabetic ulcer.

A review of the Wound/Skin Physician Orders (WSPO), dated July 19, 2012 at 5 AM, showed a telephone order (TO) for the patient's two right foot diabetic wounds. The order indicated to cleanse with wound cleanser, apply hydrogel and cover with a composite dressing.

A review of the Discharge Progress Note, July 19, 2012, failed to show a physician assessment that indicated that the patient had two diabetic ulcers on his right foot. There was no documented evidence to show that the patient required treatment and services for the diabetic ulcers.

On September 7, 2012 at 10:15 AM, an interview was conducted with the WCN. She stated that the patient's two right foot diabetic wounds should have been addressed in the discharge summary.

3. On September 6, 2012, Patient 5's medical record was reviewed with the Wound Care Nurse (WCN).

A review of the face sheet showed that Patient 5 was admitted to the facility on August 11, 2012 with a diagnosis of hematuria (blood in urine).

A review of the History and Physical for Patient 5, which was dictated on August 12, 2012, indicated that the patient had a sacral (tail bone), Stage II, PU.

A review of the Discharge Summary for Patient 5, which was dictated on August 17, 2012, failed to show that the patient received care and services throughout the hospital course for the sacrum, Stage II, PU.

On September 6, 2012 at 1 PM, an interview was conducted with the WCN. She stated that the patient's sacrum, Stage II, PU should have been addressed in the discharge summary.