HospitalInspections.org

Based on record review and interview the hospital failed to ensure that policies and procedures were followed for 1 (#1) of 5 patients sampled specific to documentation of an in-house acquired skin issue per hospital policy and the care plan. The hospital failed to ensure that a physician was notified of a blood sugar was over 400 per physician's orders stated on the plan of care.

Findings:

1) The nurse documented that on 1/26/14 at 12:35 AM Patient #1's blood sugar was documented as 403 and 14 units of Regular Insulin was administered as ordered by the physician. The physician's order indicated to call physician for any blood glucose over 400.
No documentation that the nurse called the physician.


An interview was conducted on 9/30/14 at 11:38 AM with the risk manager stated that there is no documentation that the nurse called the physician for the blood sugar results on 1/26/14 at 12:35 AM.

2.) A record review for Patient #1 revealed that on 1/16/14 Patient #1 ' s pressure ulcer risk assessment is documented as 14. If total Braden score is 15 or less then trigger wound care, physical therapy and nutritional services.
The nurse ' s notes showed that on 1/17/14 7P-7A documented that Patient #1 had dressings to bilateral groins. Coccyx cream applied. The pressure ulcer risk assessment scale is blank. The nurse ' s notes dated 1/18/14 7AM to 7 PM revealed that Patient #1 has a reddened area noted on the coccyx and groin area cream applied. Patient #1 ' s pressure ulcer risk assessment was 19. There were " no needs identified " checked on the pressure ulcer assessment.
The nurse ' s notes dated 1/18/14 7PM to 7 AM revealed that Patient #1 has a reddened area noted on the coccyx and groin area; cream was applied. Patient #1 ' s pressure ulcer risk assessment was 19. The nurse documented that there were no needs identified (checked on the pressure ulcer assessment).
A photographic documentation form dated 1/19/14 is blank. Across the top is written " no printer to print photo. " The wound location, RN signature and physician signature areas are all blank.

A review of the nutritional assessment documented by the dietitian dated 1/17/14 revealed that nursing requested a nutritional assessment due to the having nausea on days when receiving chemotherapy. The nutritional assessment did not address skin conditions or pressure ulcer concerns.

A review of the physician ' s orders, progress notes or dictated physician ' s notes does not address skin conditions, pressure ulcers or treatments.

A review of the hospital policy titled " skin and wound care management " reviewed 3/14 on page 1 paragraph 4 " pressure ulcers or any other wounds identified at the time of admission or during the hospital stay will be documented on the wound care assessment and documentation sheet. The initial assessment and on-going wound care documentation should include: location of the wound, wound measurements in centimeters length, width and depth. All wounds are to be measured on Wednesdays and documented. Photographs of any wounds or pressure ulcers will be obtained on discovery.

An interview with the unit manager of the 2 North unit on 10/1/14 at 10:50 AM stated that she does not recall Patient #1.

An interview with the risk manager on 10/1/14 at 10:50 AM stated that this surveyor identified the issues with Patient #1 ' s wounds during a previous investigation and the hospital has since had a re-visit survey in which the citation was cleared.