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LOUIS A WEISS MEMORIAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Surveyor 19843
Repeat deficiency
A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, for 2 of 2 patients (Pt. #1 and #2) with wounds on the 8 South Medical-Surgical Unit and 6th Floor Telemetry Units, that the Hospital failed to document the measurements of all wounds.
Findings include:
1. Hospital policy titled: "Skin Care Protocol" was reviewed on 7/14/09 at 12:20 PM. The policy required: "Assessment:... Documentation: 2. If skin breakdown is present and/or Braden risk score less than 16 conduct a skin assessment and document the findings daily..."
2. On 7/14/09 at 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 70 year old female, admitted on 7/6/09, with a diagnosis of Abdominal Pain. The initial nursing assessment completed on 7/6/09 indicated no skin breakdown on admission. The Altered Skin Integrity Flow Sheet on 7/13/09 at 8:45 PM included a Sacral Decubitus with pictures. However, documentation of wound measurement (length, width, and depth) was lacking.
3. On 7/14/09 at 11:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was an 85 year old female, admitted on 7/10/09, with diagnoses of Right Arm Swelling, Sepsis, and Renal Failure. The Altered Skin Integrity Flow Sheet dated on 7/10/09 included multiple wound with pictures. However, documentation of wound measurement (length, width, and depth) was lacking.
4. These findings were conveyed to the Director of Quality during interviews on 7/14/09 at 10:30 AM and 11:40 AM, during the tour.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Repeat deficiency
A. Based on review of Medical Staff Rules and Regulation, medical record document review, and staff interview, it was determined that the Hospital failed to ensure that all medical records were completed within 30 days of discharge.
Findings include:
1. The Medical Staff Rules and Regulations were reviewed on 7/14/09 at 2:50 PM. The Rules and Regulations required: "4.12.1 Records will be completed within 30 days of discharge."
2. A Weekly Deficiency Percentage of delinquent medical records was reviewed on 7/14/09 at 2:50 PM. The document included 2,629 medical records that were incomplete greater than 30 days from discharge.
3. This finding was conveyed to the Medical Director on 7/14/09 at 2:55 PM