HospitalInspections.org

Based on medical record review and staff interview, it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care of one (#3) of four patients sampled.

Findings include:


Review of the patients medical record revealed the patient was admitted to the facility on 10/22/09 following a fall at home. Results of x-rays revealed the patient had a fracture through the right acetabulum and the right inferior pubic ramus. An orthopedic consult was ordered and completed on 10/23/09. The initial plan was non surgical treatment with bedrest, pain management, and then mobilization by physical therapy. Review of physician progress notes revealed the patient was not progressing and a discussion between the patient, the patient's spouse, and the physician it was determined a surgical repair was deemed reasonable and appropriate for repair of the acetabulum fracture. Review of the medical record revealed the patient had surgery on 10/27/09. Review of the operative report revealed the patient left the operating room in a bulky Robert-Jones type dressing.

Review of the nursing assessment from 10/27/09 through the date of discharge on 11/02/09 revealed a skin integrity assessment each shift that the patient's skin was "not intact". There was no documentation which revealed why the skin was not intact and no description of where the skin was not intact. There was no documentation of the presence of a dressing.
Interview with the Clinical Informatics Director on 4/23/10 at 12:25 p.m. confirmed the above findings.