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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.

26500

Based on interview and record review, the facility failed to have a well-organized nursing service to provide 24-hour nursing services to all patients by failing to:

1. Ensure that for 1 of 8 sampled patients (Patient 1), received treatments as ordered by the physician (Refer to A-0395).

2. Ensure that for 3 of 8 sampled patients (Patient 1, 3 and 5), pressure ulcers were thoroughly assessed (Refer to A-0395).

These cumulative effect of these systemic problems resulted in the hospital's failure to deliver patient care in a safe manner and in compliance with the condition of Participation for Nursing Services.


28020

26500

Based on interview, record and policy and procedure review, the hospital failed to ensure that the Registered Nurses (RN) conducted thorough wound assessments for 4 of 8 sampled patients (Patients 1, 3, 4 and 5) when the patients presented to the emergency department and upon admission. The facility failed to ensure that the RNs worked within their scope of practice when nurses administered topical wound care treatments that were not ordered by a physician for 1 of 8 sampled patients (Patient 1).

1. For Patient 1, the hospital failed to ensure that the RNs consistently identified and thoroughly assessed the patient's left buttock, Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed), pressure ulcer (PU). The hospital failed to ensure that after admission to the facility, the RNs administered the wound care treatment to the patient as ordered by the physician.

2. For Patient 3, the hospital failed to ensure that the RNs and physicians thoroughly assessed the patient's sacrum (tail bone), Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle), PU when the patient presented to the emergency department.

3. For Patient 5, the hospital failed to ensure that the RNs and physicians thoroughly assessed the patient's sacrum, Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed), PU.

4. For Patient 4, the hospital failed to ensure that the RNs thoroughly assessed the patient's left foot diabetic ulcer when it was first identified.

These failures had the potential to contribute to adverse events, such as adverse drug reactions, wound infections, or PU wound progression (from Stage II to a Stage IV) for all patients that received services in the hospital.

Findings:

On September 4, 2012, a review of the facility's Nursing policy and procedure titled, "Skin Integrity," dated June 2012, was conducted and revealed the following:

"Purpose: To provide guidelines for assessment of skin integrity, to determine risk of developing pressure ulcers, to develop a plan of care for prevention of pressure ulcers in those patient determined to be at risk and to provide guidelines for treatment.

Assessment and Monitoring of Wounds: Staging of pressure ulcers should be deferred to wound care nurses (WCN), and physicians.

Staging:
Stage I- intact skin with nonblanchable redness or a localized area
Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed
Stage III- Full thickness skin loss
Stage IV- Full thickness tissue loss with exposed bone, tendon , or muscle

Skin Integrity: The patient's skin integrity from head to toe will be assessed upon admission by RN. Each consecutive shift, the data collection may be performed by either RN or Licensed Vocational Nurse (LVN).

Braden Scale: The RN or Licensed Vocational Nurses (LVN) will use the Braden Risk Assessment Tool when assessing patient's skin. The Braden Scale (BS) is used on admission and each shift to evaluate the patient's risk of developing pressure ulcers. Patients with a Braden score or 18 or less are at risk of developing pressure ulcers.

Wound Assessment: The RN or LVN will document their assessment of each wound by including the following in their documentation but should not be limited to the following:
Location- wound or ulcer location on body
Size- length (L) x width (W) x depth (D) in centimeters (cm)
Undermining/Tunneling- measure the extent/depth

Photographing: Wounds should be photographed, upon admission, and day discharge from the hospital. All photographed wounds, pressure ulcers and skin aberrations to be posted on the Wound Photograph Documentation Form in the patient's medical record."

On September 4, 2012 at 10:30 AM, an interview and document review was conducted with the Wound Care Nurse (WCN). She stated that the facility's document titled, "Wound Assessment/ Photographic Wound Documentation," (WAPWD) was used by the facility to document nursing and physician assessment as follows:

Nursing Assessment section included - wound location, size, tunneling, undermining, wound color, peri-wound appearance, drainage amount, drainage type, odor and pain. A section was provided for registered nurse signature, date and time.

Physician Assessment section included - present on admission, classification (pressure ulcer [stage]), diabetic ulcer (wounds that may form on the feet of individuals with diabetes mellitus), venous ulcer (wounds that may form on the feet of individuals with peripheral vascular disease), surgical wound, skin tear, and severity (acute, chronic). A section was provided for physician signature, date and time.

The document had a designated place for the photographic documentation.

On September 4, 2012 at 11 AM, an interview and document review was conducted with the WCN. She stated that the facility's document titled, "Wound/Skin Physician Orders," (WSPO) was used to document the patients' wound consultation evaluations and the physician orders for wound care treatments.

1. On September 5 2012, Patient 1's medical record was reviewed with the WCN.

A review of the face sheet showed that Patient 1 was admitted to the facility on August 16, 2012 with a diagnosis of respiratory failure (a condition relating to breathing function or the lungs themselves characterized by the lungs not functioning properly).

A review of the document WAPWD, completed in the Emergency Department (ED), dated August 16, 2012 at 4:11 PM, indicated that the patient had a coccyx (tail bone) blister (skin vesicle filled with serous fluid). The Nurse Assessment section was incomplete, it did not include wound measurements, tunneling/undermining, periwound appearance, drainage, or pain presence. The Physician Assessment section was blank, it did not include the wound stage, wound type, severity, physician's signature, date or time. The photographic documentation showed two open areas on the patient's left buttock, not the coccyx. The WCN confirmed that the wound location was reported incorrectly and that the physician did not complete a wound assessment.

A review of the patient's admission WAPWD, dated August 16, 2012 at 10 PM, documented a left buttock wound and sacral redness. The Physician Assessment section was left blank, it did not include the wound stage, wound type, severity, physician's signature, date or time. The WCN confirmed that the wounds were not staged by the physician.

A review of the patient's Braden Scale score from admission on August 17, 2012 through discharge on August 21, 2012 was conducted and showed that these scores ranged between the values of 11 and 14. According to the scale scores, Patient 1 had a high to moderate risk for developing pressure ulcers.

The facility's Pressure Ulcer Prevention Guidelines/Protocol included to manage moisture keep skin dry and protect from friction; wash gently with mild skin cleaners or warm water; use moisture barrier to protect skin moisture. The WCN stated that when the skin protocol required the application a moisture barrier to protect the skin the nurses should have used the Critic-Aid Clear-Moisture Barrier Protective Ointment (a topical wound care treatment).

A review of the admission physician orders (PO), failed to show that there was a topical wound care treatment ordered.

A review of the August 16, 2012 at 11 PM, wound assessments showed that the patient had a left buttock wound and sacral redness. The left buttock wound measurement was 1.1 x 1.1 cm. A RN applied hydrogel and a foam dressing to the left buttock wound. The WCN confirmed that there was no physician's order for the application of hydrogel to the left buttock wound on August 16, 2012.

A review of the Altered Skin care plan, dated August 17, 2012 at 1 AM, was conducted and it showed that the interventions included: wound care consult and skin care protocol.

A review of the August 17, 2012 at 8 AM wound assessments showed that the patient had a left buttock wound and sacral redness. There were no documented measurements. A RN applied hydrogel and a foam dressing to the left buttock wound. The WCN confirmed that there were no measurements taken and that there was no physicians order for the application of hydrogel to the left buttock wound on August 17, 2012 at 8 AM.

A review of the Interim Wound Care Nurse's (IWCN) assessment documentation, dated August 17, 2012 at 9:30 AM, showed that the patient had a partial thickness open sacral wound that measured (length) 1.2 cm x (width) 1.3 cm. The IWCN recommendation included the application of hydrogel (a topical agent that maintains a moist environment) and cover with composite dressing every three days. The WCN confirmed that the IWCN identified a Stage II on the patient's sacrum, not a left buttock wound as the photographic documentation showed on August 16, 2012.

A review of the Wound/Skin Physician Orders (WSPO), dated August 17, 2012 at 9:50 AM, showed a telephone order for the partial thickness sacral wound that measured 1.2 x 1.3 cm. The order showed to cleanse with wound cleanser, apply hydrogel to wound base, cover with composite dressing, change every three days and whenever soiled or dislodged.

A review of the August 18, 2012 at 8 AM wound assessments showed that a RN applied Hydrophilic (zinc oxide-based paste that adheres to moist, weeping wounds) wound dressing was to the left buttock Stage II PU, not the hydrogel as ordered by the physician on August 17, 2012 at 9:50 AM. The WCN confirmed the finding.

A review of the August 18, 2012 at 8 PM wound assessment showed that a RN applied Hydrophilic dressing to the left buttock Stage II PU, not the hydrogel as ordered on August 17, 2012 at 9:50 AM. The WCN confirmed the finding.

A review of the August 19, 2012 at 8 AM wound assessment showed that a RN applied a moisture barrier cream to the left buttock, Stage II, PU, not the hydrogel as ordered on August 17, 2012 at 9:30 AM.

On September 5, 2012 at 2:15 PM, an interview was conducted with the Chief Nursing Officer (CNO), she stated that expectation of the ED staff was to take a photograph of the wounds and include the date and time when patients presented to ED. The CNO acknowledged and confirmed that when the ED staff used the document, WAPWD, the document should have been thoroughly completed.

On 9/6/12 at 9:30 AM, the WCN acknowledged that there were documentation discrepancies regarding the location of the patient's Stage II PU. The WCN stated that when she returned to work on August 20, 2012, she assessed the patient and determined that the location of the Stage II was on the patient's left buttock, not the coccyx or sacrum.

She stated that the expectation was for the staff in the emergency department, intensive care unit and the medical surgical/telemetry unit to complete the WAPWD for those patients that presented to the facility with wounds and then present their assessment to the physician. The WCN confirmed that the WCN or physician shall stage the wound. She stated the RNs were expected to conduct the wound assessment and determine if the PU was partial thickness loss or full thickness loss.

As the interview continued, the WCN acknowledged and confirmed that the nurses applied wound care treatments that were not ordered by a physician. The WCN stated that the nurses should have followed the altered skin integrity plan of care (application of critic-aid clear-moisture barrier protective ointment) prior to the IWCN consultation and recommendations. She stated the nurses should have followed the physicians order once it was obtained by the IWCN on August 17, 2012 at 9:50 AM.

On September 5, 2012 at 2:15 PM, an interview was conducted with the CNO, she stated that the expectation of the ED staff was to take a photograph of the wounds and include the date and time when patients presented to ED. The CNO acknowledged and confirmed that when the ED staff used the document WAPWD, the document should have been thoroughly completed.

On September 6, 2012 at 2:15 PM, an interview was conducted with RN 2, that worked on August 16, August 18 and August 19, 2012. RN 2 confirmed that she did not apply the wound care treatment as the plan of care (moisture barrier treatment) or as the physician order (hydrogel) indicated. She stated that she did not refer to the patient's plan of care or physicians order prior to administering the topical wound care treatment to the patient's left buttock, but she should have. RN 2 stated that the facility did not have a treatment administration record (a list of current treatments). When asked how she decided to use one topical treatment versus the another, RN 2 stated that after she assessed the patient's left buttock PU, she entered the patient's name into the facility's central supply dispensing system and a drawer opened with several topical agents to select from.

On September 7, 2012 at 8:55 AM, an interview was conducted with the Emergency Department Director (EDD). He was not knowledgeable of the expectation for the ED staff to complete the document WAPWD. The EDD stated that for patients that presented to the ED with wounds, the ED staff was expected to photograph the wounds, sign, date and time the document, but no further assessment was required.

On September 7, 2012 at 10 AM, an interview was conducted with the WCN, CNO and the Director of Medical-Surgical/Telemetry (MST) unit regarding the administration of topical wound care treatments. They confirmed that the facility did not have a treatment administration record and that the patients' topical wound care treatments were not included on the patients' medication administration record. They stated that the nurses were expected to refer to the current physicians order. When asked if the pharmacy was responsible for monitoring and stocking the dispensing system for topical wound care treatments they stated, "no."

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

A review of the face sheet showed that Patient 3 was admitted to the facility on September 4, 2012 with a diagnosis of sepsis (bacterial blood infection).

A review of the document WAPWD that was completed in the ED, dated September 3, 2012 at 10 PM, showed that the patient had a sacrum (tail bone) wound. The nursing assessment did not include wound measurements, tunneling/undermining, periwound appearance, drainage, or pain presence. The physician assessment did not include the wound stage, wound type or severity.

A review of the document WAPWD that was completed on admission, dated September 4, 2012 at 4 AM, showed that the patient had a sacrum, Stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle), PU.

On September 5, 2012 at 2:15 PM, an interview was conducted with the CNO, she stated that the expectation of the ED staff was to take a photograph of the wounds and include the date and time when patients presented to ED. The CNO acknowledged and confirmed that when the ED staff used the document WAPWD, the document should have been thoroughly completed.

On September 6, 2012 at 9: 30 AM, the WCN stated that the expectation was for the staff in the emergency department, intensive care unit and the medical surgical/telemetry unit to complete the WAPWD for those patients that presented to the facility with wounds and then present their assessment to the physician. The WCN confirmed that the WCN or physician shall stage the wound. She stated the RNs were expected to conduct the wound assessment and determine if the PU was partial thickness loss or full thickness loss.

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 the urine).

A review of the WAPWD document, completed in the ED, dated August 11, 2012 at 1:20 PM, showed that the patient had a coccyx (tail bone) wound. The nursing assessment did not include wound measurements. The physician assessment sections did not include the wound stage and severity.

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 WAPWD document, dated August 14, 2012 at 4 AM, showed that the patient had a coccyx wound. The nursing assessment did not include wound measurements.

A review of the WAPWD document, taken upon the patient's discharge from the facility, dated August 16, 2012 at 1 PM, showed that the patient had a coccyx wound. The nursing assessment did not include wound measurements. The physician assessment did not include the wound stage, wound type, severity, physician's signature, date or time.

On September 5, 2012 at 2:15 PM, an interview was conducted with the CNO, she stated that expectation of the ED staff was to take a photograph of the wounds and include the date and time when patients presented to ED. The CNO acknowledged and confirmed that when the ED staff used the document WAPWD then the document should have been thoroughly completed.

On September 6, 2012 at 9:30 AM, the WCN stated that the expectation was for the staff in the emergency department, intensive care unit and the medical surgical/telemetry unit to complete the WAPWD for those patients that presented to the facility with wounds and then present their assessment to the physician. The WCN confirmed that the WCN or physician shall stage the wound. She stated the RNs were expected to conduct the wound assessment and determine if the PU was partial thickness loss or full thickness loss.

4. On September 6, 2012, Patient 4's medical record was reviewed with the Wound Care Nurse (WCN).

A review of the face sheet showed that Patient 4 was admitted to the facility on 8/11/12 with a diagnosis of diabetic foot wound.

A review of the document WAPWD completed in the ED, dated 8/11/12 at 1:21 AM, showed that the patient had a left foot wound. The nursing assessment did not include wound measurements, undermining, wound color, periwound appearance, odor, drainage or pain presence. The WCN confirmed the finding.

On September 5, 2012 at 2:15 PM, an interview was conducted with the CNO, she stated that expectation of the ED staff was to take a photograph of the wounds and include the date and time when patients presented to ED. The CNO acknowledged and confirmed that when the ED staff used the document WAPWD then the document should have been thoroughly completed.

On September 6, 2012 at 9:30 AM, the WCN stated that the expectation was for the staff in the emergency department, intensive care unit and the medical surgical/telemetry unit to complete the WAPWD for those patients that presented to the facility with wounds and then present their assessment to the physician. The WCN confirmed that the WCN or physician shall stage the wound. She stated the RNs were expected to conduct the wound assessment and determine if the PU was partial thickness loss or full thickness loss.














26502



26881



28020

26500

Based on interview and record review, the facility failed to ensure that verbal orders were authenticated to include the signature, date and time of the order by the ordering physician within 48 hours for 4 of 8 sampled patients (Patients 1, 2, 4 and 6). This failure had the potential for all patients to receive medications and/or treatments that were not according to the physician's plan of treatment, which may contribute to adverse health outcomes and harm to the patients.

1. For Patient 1, the hospital failed to ensure that the telephone orders obtained by the Interim wound Care Nurse for wound care treatment was authenticated by the ordering physician within 48 hours.

2. For Patient 2, the hospital failed to ensure that the telephone orders for an antibiotic, an antianxiety medication, a medication for insomnia, a narcotic pain medication, and wound care treatment were authenticated by the ordering physician within 48 hours.

3. For Patient 4, the hospital failed to ensure that the telephone orders for diabetic ulcer wound care was authenticated within 48 hours.

4. For Patient 6, the hospital failed to ensure that the telephone orders for diabetic ulcer wound care was authenticated within 48 hours.

Findings:

On September 5, 2012 a review of the facility's General-Medical Staff Rules and Regulations, dated May 2012, indicated that "all verbal orders for medications shall be signed, dated and timed by the ordering practitioner within forty-eight (48) hours."

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

A review of the face sheet showed that Patient 1 was admitted to the facility on August 16, 2012 with a diagnosis of respiratory failure (a condition relating to breathing function or the lungs themselves characterized by the lungs not functioning properly).

A review of the Wound/Skin Physician Orders (WSPO), dated August 17, 2012 at 9:50 AM, showed a telephone order for the partial thickness sacral wound that measured 1.2 x 1.3 cm. The order indicated to cleanse with wound cleanser, apply hydrogel to wound base, cover with composite dressing, change every three days and whenever soiled or dislodged. The WCN confirmed that the order was not authenticated to include signature, date and time by the ordering physician within 48 hours.

On September 6, 2012 at 10:15 AM, an interview was conducted with the Director of the Medical Staff. She stated that all verbal/telephone orders should have been authenticated by the ordering physician within 48 hours.

2. 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 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).

On September 6, 2012, a review of the WSPO, dated July 19, 2012, showed a telephone order (TO) for wound care for the patient's diabetic ulcers to the right first toe, right inner fourth toe, and the left lateral foot. The order showed to monitor any change, keep clean and dry. The order was not authenticated by the ordering physician within 48 hours. The WCN confirmed that the TO was not authenticated with a stamp until July 31, 2012.

A review of the document for "Pharmacy Automatic Stop Orders," showed medications that were started on July 19, 2012 and were to be discontinued on July 25, 2012. On July 25, 2012 at 6:50 PM, the nurse obtained TOs for those medications that were listed to be renewed. The documentation was faxed to the pharmacy on July 25, 2012 at 7 PM. The ordering physician did not authenticate the TOs until August 2, 2012. The list of medications were as follows:

Piperacillin/Tazobactam (antibiotic) 3.375 gm/D5W (5% dextrose in water) premix (50 ml) intravenous

Temazepam (sleep aid) 30 mg by mouth

Lorazepam (antianxiety medication) 0.5 mg by mouth

Oxycodone ( narcotic pain medication) 5 mg by mouth

Oxycodone 20 mg by mouth

On September 6, 2012 at 10:15 AM, an interview was conducted with the Director of the Medical Staff. She stated that all verbal/telephone orders should have been authenticated by the ordering physician within 48 hours.

On September 7, 2012 at 11 AM, an interview was conducted with the Pharmacy Director (PD). He reviewed the document for the "Medication Automatic Stop Orders" The PD stated that the document was considered the same as if it were on the PO sheet. He acknowledged that the TOs were not authenticated by the ordering physician within 48 hours and that they should have been.

3. On September 6, 2012, Patient 4's medical record was reviewed with the facility's WCN.

A review of the face sheet showed that the patient was admitted on August 11, 2012 with an admitting diagnosis of diabetic foot wound. The patient was discharged home on August 15, 2012.

A review of the Wound/Skin Physician Orders (WSPO), dated August 11, 2012 at 4 AM, showed a telephone order (TO) for the patient's left diabetic foot foot wound. The order indicated to cleanse with wound cleanser, apply a neomycin/polymyxin/bacitracin ointment (triple antibiotic), cover with a non-adherent dressing and gauze, and change every day and/or whenever necessary. The order was not authenticated by the ordering physician. The WCN confirmed the finding and stated that the order should have been authenticated by the ordering physician within 48 hours.

4. On September 7, 2012, Patient 6'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 left foot cellulitis. The patient was discharged home on July 27, 2012.

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. The order was not authenticated by the ordering physician until July 27, 2012 (8 days later). The WCN confirmed the finding and stated that the order should have been authenticated by the ordering physician within 48 hours.

A review of the History and Physical, dictated on July 19, 2012 failed to show a physician assessment that indicated that the patient had two right foot diabetic ulcers.

A review of the Discharge Progress Note, on 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 documentation to show that the patient required treatment and services for the right foot diabetic ulcers.

On September 6, 2012 at 10:15 AM, an interview was conducted with the Director of the Medical Staff. She stated that all verbal/telephone orders should have been authenticated by the ordering physician within 48 hours.









26881

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.