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Tag No.: A0395
14528
Based on medical record reviews, review of hospital policies, hospital documentation and interviews for one of two patients who had a pressure ulcer (Patient #9), nursing staff failed to assess the patient's pressure ulcer in a timely manner. The findings include:
Patient #9 was admitted to the hospital on 10/28/10 with diagnoses of hypoxia, bilateral pleural effusions, pneumonitis and C- difficile colitis. The skin consult dated 10/28/10 identified that the patient had a 1cm by 0.8cm by 0.1cm stage II pressure ulcer to the coccyx. The patient's medical record, to include nursing notes, physician progress notes and the skin/wound documentation form, indicated that the patient's ulcer was assessed 12 days later on 11/9/10 as a stage II ulcer that measured 0.8cm by 0.8cm. Interview with the Intensive Care Unit (ICU) Charge Nurse on 11/9/10 at 12 PM noted that pressure ulcers should be assessed every 7 days and that ICU staff assesses ulcers every Tuesday. Review of the hospital's skin/wound care policy directs staff to measure the identified pressure ulcer and record the measurements on the Skin Care/Wound Documentation Form during the initial admission assessment, weekly and with a worsening wound.
15482
19907
Tag No.: A0396
14528
Based on medical record reviews, review of hospital policies, hospital documentation, observation and interviews for two of two patients who had a pressure ulcer (Patient #9, #11), nursing failed to notify the physician of the ulcer and/or consistently document ulcer treatments. The findings include:
Patient #11 was admitted to the hospital on 11/4/10 at 10:23 PM with diagnoses of respiratory failure and chest pain. The skin/wound documentation forms dated 11/5/10 at 12:30 AM identified that the patient had 4 stage II pressure ulcers to the right buttock/coccyx and criticaid was applied to the areas. Although the plan of care dated 11/5/10 noted the problem of the 4 stage II pressure ulcers, the section for documentation of the pressure ulcer treatment was left blank. Review of the patient's record with the 5.2 unit nurse on 11/9/10 at 1:10 PM noted that nursing 24 hour flow records and/or nursing narratives from 11/6/10 on the night shift to 11/7/10 on the evening shift lacked documentation of treatment to the ulcerated areas.
Patient #9 was admitted to the hospital on 10/28/10 with diagnoses of hypoxia, bilateral pleural effusions, pneumonitis and C- difficile colitis. The skin consult dated 10/28/10 identified that the patient had a 1cm by 0.8cm by 0.1cm stage II pressure ulcer to the coccyx, the physician was notified and recommended a foam dressing every three days or skin barrier cream if the foam dressing did not remain in place. The plan of care dated 11/3/10 to 11/9/10 noted, "offload" as the pressure ulcer treatment to the coccyx. Nursing documentation dated 11/4/10 to 11/9/10 identified that a foam dressing was applied to the coccyx area on 11/4/10, Criticaid (cream) was applied twice thereafter and additional and/or consistent pressure ulcer treatment was not documented. Although the 24- hour flow sheets from 11/5/10 through 11/9/10 denoted a box for each shift nurse to check when/if barrier cream was applied this had not been documented. Interview with Patient #9's nurse on 11/9/10 at 12:10 PM noted that the foam dressing did not stay in place due to the patient's frequent loose stools and barrier cream was applied after each episode. The hospital documentation policy identified that the patient care plan served as a rapid reference for active problems and that each problem, goal, and intervention is identified, prioritized, dated and signed. Interventions that are deemed appropriate are checked off or written in on the care plan. The policy further noted that the 24- hour flow sheet was used to coordinate documentation of patient care.
15482
Tag No.: A0404
Based on medical record reviews, review of hospital policies and interviews for one patient who received titrated medication (Patient #8), the hospital failed to follow the physician's order for titration. The findings include:
Patient #8 was admitted to the hospital with a diagnosis of left upper lobe lung mass. Physician orders dated 11/3/10 directed Levophed 4mg/250ml D5W start at 4mcg/min to a maximum dose of 30mcg/min and titrate by 2mcg/min every three minutes. The order lacked blood pressure parameters (left blank). Interview with the Intensive Care Unit Nursing Manager on 11/9/10 at 11:30 AM noted that the physician would usually write an order to maintain the systolic blood pressure above a specific level. Review of the facility guideline for safe medication practices indicated that titrating orders are acceptable provided there are parameters.
In addition, Patient #8's flow records identified that the Levophed was initiated as ordered at 10:30 PM on 11/3/10 and the patient's blood pressure was 71/47. Review of the patient's flow sheets dated 11/3/10 from 10:30 PM to 11:36 PM with the ICU Manager on 11/9/10 at 11:30 AM noted that the patient's Levophed was titrated from 4mcg/min to 8mcg/min, increments times varied and did not occur every 3 minutes as ordered.
15482