HospitalInspections.org

Based on interview and record review, the facility failed to ensure keeping the care plan current in the form performing prescribed wound care and dressing changes form 1 of 6 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. Physician orders of 11/03/10 read, "Wound care to bil (bilateral) buttocks. Cleanse with normal saline. Apply Xenaderm to open area & surrounding intact red & purple discoloration. Cover with Adaptic. Repeat TID (three times a day)."

Regarding these orders, nursing documentation revealed that there was only one clearly designated episode of wound care and a dressing change on 11/10/10 (orders were for three a day). This took place at 8 AM. A wound photo was also taken at 2 AM, which could have only been performed with a removal of a wound dressing. Excluding this six hour time window (2-8 AM), there were no episodes of wound care or dressing changes during the remaining eighteen hours. In addition, there was no evidence of the performance of any of the three required wound care sessions and dressing changes on 11/15/10.

The findings were confirmed in an interview with the Assistant Director of Risk Management on 4/19/11 at approximately 6 PM.