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Tag No.: A0395
Based on medical record review and staff interview the facility failed to ensure wound care was provided to a patient that was assessed with large amounts of sanguineous drainage from a surgical incision of the lower extremity. This affected one, (Patient #1) of ten medical records reviewed. The hospital census was 445.
Findings include:
On 04/12/16 the medical record for Patient #1 was reviewed. The patient had multiple admissions including an admission on 03/02/16 for surgical procedures including a right aorobifemoral bypass, a right popliteal embolectomy, and an infusion intra-arterial tPA.
Nursing flow sheets from 03/02/16 through 03/14/16 documented wound care for surgical incisions of the right upper medial leg, the right upper arm, the right abdomen, and the right groin as a result of the surgical procedures.
The surgical incision of the right upper medial leg was documented with moderate amounts of sanguineous drainage and dressing changes on 03/02/16 and 03/03/16. On 03/05/16 the right leg incision was documented with large amounts of sanguineous drainage; however, the record lacked documentation of dressing changes between 8:30 PM on 03/05/16 and 5:27 PM on 03/06/16 (21 hours).
The daily cares/safety flow sheet on 03/06/16 at 5:14 PM documented Patient #1 required a gown change, a bed pad change, and a bed linen change.
Surgeon notes dated 03/03/16, 03/04/16, 03/05/16, 03/06/16 document "dressing with soakthrough".
On 04/13/16 at 10:00 AM Staff A confirmed the drainage documentation and stated the gown, bed pad, and linen changes were most likely due to the patient's large sanguineous drainage without proper care over the 21 hour period between 8:30 PM on 03/05/16 and 5:27 PM on 03/06/16.