HospitalInspections.org

Based on the review of medical records, it was determined that in one of one medical records, Patient # 1, the hospital failed to ensure that nursing staff developed and kept current a nursing care plan for each patient. Findings include the following:

Patient # 1 was admitted to St. Charles Medical Center - Bend on 07/19/2012 and discharged to Legacy Rehabilitation Institute of Oregon on 09/07/2012. A nursing care plan was developed on 07/19/2012 in ICU, continued after the patient was transferred to the General IMCU (intermediate care unit) on 08/03/2012, and continued when the patient was transferred to the Ortho/Neuro unit on 08/20/2012.

On 08/02/2012 the patient received a wound care evaluation and it was noted that the patient had a "reddened buttocks" and the patient's scrotal area was irritated. By 08/04/2012 the patients coccyx was described as erythematous, i.e. reddened skin due to capillary dilatation. A Stage 1 pressure ulcer is defined as a "nonblanchable erythema of intact skin" as found in "Clinical Nursing Skills, Basic to Advanced Skills, Fourth Edition," Smith & Duell, pg. 692. A wound care team member visited the patient on 08/10/2012 and identified a "0.3 cm X 0.3 partially open ulcer present on the patient's sacrum."

The 5-day nursing care plan for 08/05/2012 through 08/09/2012 lacked any entries within the INTEG (Integumentary system) section of the plan. The 5-day nursing care plan for 08/10/2012 through 08/14/2012 lacked any entries within the INTEG section of the plan. The nursing care plan failed to address these changes in the patient's condition.