HospitalInspections.org

Based on record review, review of facility policies, and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care related to physician ordered plan of care and assessments or 1 (#1) of 6 patients sampled. This practice does not ensure patient care needs and goals are met.

Findings include:

1. Review of patient #1's medical record revealed a physician order on 1/02/11 for ? inch Iodoform gauze packing to the chest wound and change daily. Review of the nursing documentation revealed no documentation the wound was packed daily as ordered. Review of the physician orders on 1/06/11 revealed wound care to multiple areas and dressing changes daily. Review of the nursing documentation revealed several days during the patient's admission of 12/23/10 to 1/22/11 that the dressing was not changed according to physician orders.

Review of the facility's policy and procedure, Care of the Patient Requiring Skin Care, indicates the patient's skin will be assessed every shift, and observations and interventions documented including location, size and drainage.

The nursing staff failed to indicate the size of the wounds consistently during the admission of 12/23/10 to 1/22/11.

Interview on 1/28/11 at 2:30 p.m. with the Safety and Regulatory Manager confirmed the dressing changes were not documented according to physician orders.

Based on staff interview and review of clinical records it was determined that the facility failed to ensure the nursing staff developed and kept current a nursing care plan for 2 (#1, #4) of 6 records sampled. This practice does not ensure patient goals are met.

Findings include:

Review of the facility policy, "Nursing Documentation", states for patients with a Braden Score of 18 or less, nursing should address the skin section on the Plan of Care every 24 hours.

1. Review of the medical record for patient #1 revealed the patient was admitted on 12/23/10 at 7:53 p.m. A plan of care was initiated on 12/24/10. The patient's Braden Score on 12/24/10 was 15. Review of the documentation revealed the patient's Braden Score was assessed daily and documented. Review of the daily Braden Score revealed the patient's range was 8-18. Review of the patient's Plan of Care revealed the skin section was not addressed on 12/27/10, 12/28/10, 1/02-1/07/11, 1/14/11, 1/15/11, and 1/18./11

Interview with the Safety and Regulatory manager on 1/28/11 at 2:30 p.m. confirmed the above.

2. Review of the medical record for patient #4 revealed the patient was admitted on 1/21/11. Review of the history and physical revealed the patient had a history of dementia. Review of the nursing assessments and physician progress notes revealed the patient had several bilateral foot ulcers and required assistance for repositioning. Review of the patient's plan of care revealed skin was not addressed from 1/24 - 1/27/11.

Interview on 1/28/11 at 1:30 p.m. with the nurse manager confirmed skin section of the patient's plan of care was not addressed.