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Based on wound care order sets, staff competency test review, policy review, medical record review, and staff interviews, the nursing staff failed to evaluate and supervise the delivery of patient care by failing to apply a correct dressing to a wound in 1 of 2 sampled emergency room patients with wounds (Patient #1); and failing to
follow a physician order to elevate the head of bed greater than thirty degrees for 1 of 6 patients (Patient #6) on aspiration precautions.

The findings include:

1. Review of the Emergency room wound care order sets revealed skin care for skin tears. "Skin Tears...1. Cover injury with petroleum gauze and roll gauze. May use on skin tears with minimal exudate. 2. Cover injury with petroleum/bismuth gauze (Xeroform) and roll gauze. 3. Silicone foam 3x3 dressing (Allevyn) for skin tears with moderate exudate...."

Review of "Nurse Tech Blitz Questions Test" dated 2019 revealed "....7. When cleaning and dressing a wound, apply a nonstick pad on the patient's skin prior to wrapping the site...."

Closed medical record review revealed an 85 year old male that presented to the Emergency room on 03/02/2019 at 1148 with complaints of accidental tripping and falling on the concrete of his driveway earlier in the day. Record review revealed the patient sustained injuries to his head, face and right hand. Review of physician provider Emergency Department notes dated 03/02/2019 at 1601 revealed "...Significant ecchymosis (bruising) surrounding the right eye. Superficial abrasion lateral to the right eye...Right upper extremity: 10 x 10 cm (centimeters) skin tear on the dorsum of the right hand..."

Review of a nursing communication order dated 03/02/2019 at 1458 revealed "Completed: ...After x-rays, please apply a dressing to the skin tear on his right hand..."

Review of nurse technician's (NT #1) wound procedure note dated 03/02/2019 at 1457 revealed "....Cleaned; Sterile dry gauze; Pressure applied. Wound dressing: Sterile gauze..."

Interview on 04/23/2019 at 1455 with NT #1 revealed remembering performing dressing care to the patient's skin tear. "EMS had applied tegaderm. The tegaderm was removed, wound was cleansed with Surclenz (a wound cleanser spray), dried with sterile gauze, and covered with gauze, then wrapped with roll gauze, and secured with medipore tape."

Interview on 04/24/2019 at 1005 with Director of Emergency Department revealed the skin tear should have been covered with non-adherent dressing not gauze. Interview revealed dressing was not performed according to recommendations and education taught in class.



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2. Review of the hospital policy titled "Nursing Process and Physical Assessment Standards" effective 10/18/2018 revealed "...Nursing Process ...Interventions documented as soon as possible after the time of completion ..."

Closed medical record review on date revealed Patient #6 was an 82-year old male who was admitted to the hospital on 03/18/2019 with a diagnosis of aspiration pneumonia and discharged on 04/11/2019 to a skilled nursing facility. Medical record review revealed a physician order on 03/28/2019 at 1225 to "...Elevate HOB (head of bed) greater than 30 degrees..." Review of Patient #6's "mobility flowsheet" revealed documentation on 03/28/2019, 03/29/2019, 03/31/2019, 04/01/2019, 04/07/2019 and 04/09/2019 that showed the head of bed was elevated 30 degrees. Review failed to revealed Patient #6's head of bed elevated above 30 degrees per the physician order.

Telephone interview with Registered Nurse (RN) #2 on 04/25/2019 at 1415 revealed nursing staff entered the degree of elevation on the touchscreen of the patient's electronic bed and the bed automatically adjusted to that level. Interview revealed nursing staff documented the degree of elevation in the flowsheet of the electronic health record. RN #2 reported if there was no documentation of change in the degree of elevation the nursing staff did not document it or it was not changed. Interview confirmed there was no documentation that the head of bed was elevated greater than 30 degrees per the physician order.

Interview with the unit nurse manager on 04/24/2019 at 1140 revealed nursing staff were expected to document interventions and the patient's response in the electronic health record.

NC00149402; NC00150050; NC00149718