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On the days of the Complaint Survey based on interview and clinical/facility record review, the hospital failed to ensure that medication/treatment orders were received from the physician for the care and services related to decubitus care for 1 of 8 open patient records (Patient #3) and 1 of 2 closed records reviewed.(Patient #10)


The findings include:


On 04-30-12 at 1145, record review for Patient #3 revealed the patient was admitted on 04-27-12 with the diagnoses of Nausea,Vomiting, and Abdominal Pain. Review of the nursing assessment in the patient's record revealed staff documented a decubiti on the patient's left shin that measured 3cm(cubic centimeter) x 3 cm, Stage 2. On 04-30-12 at 1230, Registered Nurse(RN)#5 reported the patient's dressing was changed daily, and the wound care measurements and description of the wound was placed on the physician order sheet for the physician's review. RN #5 stated that the documentation on the physician served as notification to the physician of the patient's wound. RN #5 reported that since the physician had not ordered wound care based on the documented patient assessment, it was assumed the physician didn't want any wound care.

On 04-30-12, closed record review revealed Patient #10 was admitted to the hospital from the Emergency Department on 12-27-11 with the diagnoses of Chest Pain, Shortness of Breath, Headache, and Pain. Patient #10 was discharged to a hospice house on 03-03-12 with the discharge diagnoses of Hyperkalemia, infected right upper arm Arteriovenous(AV) Graft with Methicillin-Resistant Staphylococcus Aureus Sepsis, Respiratory Failure, a large Sacral Decubitus Ulcer, End Stage Renal Disease, Nonischemic Cardiomyopathy, a Gastrointestinal Bleed requiring blood transfusions, and Dysphagia requiring a Percutaneous Endoscopic Gastrojejunostomy(PEG) tube placement. The patient's hemodialysis's order dated 12-27-12, reads, "...Heparin bolus 2000 units, then 1000 units/hour times 3-4 hours". Review of the patient's hemodialysis flow sheet on 12-27-12, revealed Hemodialysis orders which showed the Heparin order was crossed out, and written as, " Tight-catheter placement 1000 unit bolus and 500 units times 2 1/2 hours." Review of the dialysis treatment flow sheet in the patient's chart revealed the patient's dialysis treatment was started at 1655 and a 'bolus" of heparin units was written but the note did not show the amount of heparin administered. The dialysis flow sheet showed 0.3 units of heparin was administered at 1730. At 1745, documentation showed the vascular access system clotted off, was resumed at 1745, but no additional heparin units were administered.
On 05-03-12 at 1630, during an interview with the Dialysis Charge Nurse, he/she revealed that staff intended to use the dialysis catheter but the catheter wasn't working. The Dialysis Charge Nurse reported that it was standard practice when a patient has a new catheter to decrease the amount of heparin. The Charge Nurse had no explanation as to why the documentation failed to show any additional units of heparin were administered rather than decreased.

Review of facility policy, titled, Heparin Requirements, reads, "...Tight Fractional. Bolus dose 15-20 u(units)/kilogram(kg) followed by half hourly assessment of clotting (see section 132-020-320) to determine need for additional dose of 7-8 units per 1 kg normal (dry) body weight. Example: 70 kg patient. Initial Bolus: 70 kg x 20 u/kg= 1400 units. Tight fractional dose ( every 30 minutes, as needed): 70 kg x 8 u/kg= 560 units, 600 unit dose."

Review of Fresenius Clinical Services policy, titled, Heparin Administration Procedure, reads, "...Step 2 verify the physician orders and/or consult if assessment warrants risk of bleeding and potential changes in medication....Documentation: Document all required information on the treatment record: medication administered, dose, route, time and patient's response....".