HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 1 RN (Registered Nurse) Staff #3 obtained physician's treatment orders for a documented skin tear located on 1 of 1 patient (Patient #1's) gluteal fold.

Findings included:

(Patient #1's) physician medicine and rehabilitation consult dated 10/02/12 reflected, "76 year old male with history of prostate cancer admitted to...hospital due to swelling and intractable bone pain...reports having had weakness in both lower extremities...continues with physical therapy..."

The All Flowsheet Data record dated 10/02/12 reflected, "Skin...small skin tear between upper gluteal folds...skin care protocol implemented..."

The All Flowsheet Data record dated 10/03/12 reflected, "Skin...small skin tear between upper gluteal folds..."

The physician's orders dated 10/02/12 through 10/03/12 reflected, no documentation which indicated treatment orders were obtained for the skin tear to (Patient #1's) gluteal fold and applied to the site.

On 02/08/13 at approximately 11:00 AM Staff #3 was interviewed. Staff #3 stated she found a skin tear on (Patient #1's) gluteal fold. Staff #3 was asked by the surveyor what treatment she initiated for the skin tear and did she obtain physician's orders. Staff #3 stated she used her "Nursing Judgment." Staff #3 stated she could not remember what cream she applied to the site and stated no physician's orders were obtained.

On 02/08/13 at approximately 11:40 AM Staff #6 was interviewed. Staff #6 stated the physician should be notified of a skin tear. Staff #6 was asked if the hospital had a protocol for skin tears. Staff #6 stated the hospital had no written protocol, but the nurse would need to contact the physician and obtain treatment orders.

The Texas Board of Nursing Standards of Nursing Practice Title 22, Part II, Chapter 217, Rule 217.11: reflected, "The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure...failure to meet these standards may result in action against the nurse's license even if no patient injury resulted...(D) accurately and completely report and document (i) the client's status including signs and symptoms (ii) nursing care rendered (iv) administration of medications and treatments..."