HospitalInspections.org

Based on review of Policy and Medical Record and Interview with hospital staff the Hospital General Provision Requirement was not met TAC Rule 141.454 was not met and therefore the requirement to keep current a nursing care plan for each patient was not met. General Provision requires a hospital to:

"(a) Written Policies and Procedures: A hospital shall develop written policies and procedures that ensure compliance of this subchapter.

(b) Compliance by staff. All staff member shall comply with this subchapter and the policies and procedures of the hospital required by subsection (a) of this section.

(c) Responsibility of hospital. A hospital shall be responsible for a staff member's compliance with this subchapter and the policies and procedures required by subsection (a) of this section.

(d) Enforcement of Policies and Procedures: A hospital shall take appropriate measures to ensure a staff members compliance with this subchapter and the policies and procedures required by subsection (a) of this section ....."


Findings:

a. The hospital policy entitled " Guidelines for the Identification, Prevention, and Management of Pressure Ulcers " last revised 09/14 page 5 of 8, C. Documentation of Pressure Ulcers it states under 2.

" The nurse will take a photograph of the pressure ulcer(s) to include healed or scarred ulcers and place in the patient ' s medical record at the following times
a. As soon as possible when the patient is admitted or when the pressure ulcer is discovered
b. Weekly, to assess response to treatment, every Sunday (or at next scheduled dressing change, if Wound VAC in place)
c. When the patient is discharged or transferred to another level of care
d. When there is a significant change in status such as wound deterioration or a healed wound. "

b. A thorough review of the patient's medical record did not show evidence of photographs of the progression or result of treatment of the patient's pressure sores. Even though other documentation in the nurses notes and physician progress notes did describe the care that was given for these sores.

c. Interviewed staff #6, wound care nurse at 3:20pm on September 10, 2015 via telephone while in the facility who was familiar with the patient and his care. He explained that he is in the facility three times out of the week and had trained the nursing staff on that unit to care for the patient on the days he is not in and they had his number to call if any issues arises. He explained the wound care that was rendered for the patient and talks with the family. He admitted the photograph of the wounds with measurement plus care given should be in the patient's record. It was explained to him that there were no photographs of the patient wounds in the medical record.

d. Interviewed staff #5, Registered Nurse (RN) at 3:30pm on September 10, 2015 and staff # 2 at 3:50pm on September 10, 2015 and re-confirmed (via telephone) on November 12, 2015 in the nursing conference room who also confirmed they did not see the photographs of the patients wounds.