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Based on hospital policy, record review and staff interview, it was determined in 1 of 10 patient (Pt #1), the nurse failed to follow policies and physician orders in providing care for the patient. This failure has the potential to affect all inpatients.

Findings include:

1. A review of the hospital standard operating procedure titled "Wound and Ostomy Management, dated 3/9/12 was completed on 10/13/15 at approximately 4:15 PM. The procedure under "patients being serve include patients: with superficial skin breakdown. Referrals for Inpatient Wound care are made when the patient: develops an open wound, including any of the above wound types." The policy titled "Wound/Pressure Ulcer Prevention and Management" was reviewed on 10/14/15 at 2:30 PM. This policy dated 1/8/13 under POLICY, paragraph 2, "Patients presenting with or developing pressure ulcers or wounds receive assessment, care and treatment... The RN obtains physician orders for the care and treatment necessary for prevention, when indicated . The policy indicates under VI DOCUMENTATION, 1.0 Document in the medical record: 1.1 Any procedure of assessment related to pressure ulcer prevention. ... B. Interventions taken...C. Response to interventions, 1.2 All wound assessment or treatment data, A. Appearance, location, size..."

2. A review of the medical record of Pt #1 was completed during the survey. Pt #1 was a direct admission from the receiving hospital on 7/26/15 at 2308 with a diagnosis of left hip periprosthetic fracture and hypertension. A photograph dated 7/27/15 at 1315 which was included in the record was taken of Pt # 1's left buttock. Pt # 1's left buttock was described in the nurse notes dated 7/27/15 at 1411 as an "abrasion". There was no documentation to indicate the physician was informed. There was no documentation of a description of the "abrasion", including appearance, size, depth and width. There was no documentation of any treatment to the "abrasion" until 7/29/15 at 1411, just prior to discharge, which was application of a dry dressing. There was no documentation of a referral to "Inpatient Wound Care" per the hospital policy.

3. An interview was conducted with Quality Improvement Manager (E#3) on 10/15/15 at 8:30 AM. E#3 reported she reviewed Pt #1's record and did not locate any documentation of the details of the wound assessment, report to the physician, orders for treatment or care provided to the "abrasion" except for the dry dressing. E#3 agreed the policies were not followed for assessment, treatment and referral for Pt #1's wound.

4. A review of Pt #1's medical record included a telephone order dated 7/26/15 at 0117 for "Anti-embolic Stockings (TED). An order dated 7/27/15 at 2145 was for "Anti-Embolic Stockings (TED) status CNC (cancel). There was no documentation to indicate the TED stockings were applied for Pt #1 at any time prior to the cancel order.

5. In an interview with E#3 on 10/14/15 at 3:30 PM, E#3 reviewed the electronic record and agreed there was no documentation to indicate the anti embolic (TED) stockings were applied per the physician orders.

Based on document review and staff interview, it was determined in 1 of 10 patient (Pt #8), the hospital failed to ensure contact isolation precautions were implemented when ordered by a physician. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. On 10/14/15 at 2:00 PM, the electronic medical record of Pt #8 was reviewed with the Quality Improvement Nurse (E #5). Pt #8 was admitted to the Hospital on 7/26/15 with a diagnosis of health care associated pneumonia. Documentation indicated on 7/27/15, the physician ordered isolation precautions, due to a history of methicillin resistant staphylococcus aureus (MRSA) in the previous 12 months. There was no documentation in the electronic medical record to indicate the patient was placed on isolation precautions.

2. On 10/15/15 at 10:00 AM, the Hospital policy "Isolation, Standard and Transmission Based Precautions", last revised 11/2013, was reviewed. Under "Nursing staff 1.4" it reads "Document appropriately".

3. On 10/15/15 at 10:30 AM, the Hospital policy "MRSA Screening and Surveillance", last revised 11/2013, was reviewed. Under "2.1" it reads "Patients with history of MRSA infection or colonization in the previous 12 months are isolated at the time of admission and re-screened."

3. On 10/14/15 at 2:00 PM, an interview with E #5 was conducted. E #5 verbalized the medical record did not contain documentation that Pt #8 was placed on contact isolation precautions, and should have.