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Based on clinical record review, and staff interview the facility failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care. This failure affected 1 of 10 sampled patients (Patient # 10).


The findings include:


Clinical record review for Patient # 10 revealed the patient was admitted to the facility on 09/04/11 with diagnosis of Distal Left Femur Fracture.
The Initial Nursing Assessment dated 09/04/11 documents the patient ' s skin as intact; The Braden Pressure Ulcer Risk Assessment documents a score of 16 (low risk).
The Care Plan titled " Skin Impairment " dated 09/05/11 documents the goal as patient will maintain optimum skin integrity as evidenced by no further skin injury during this hospital stay. The interventions are noted as assist to off load Buchs Traction, off load heels and wound care as ordered. Further review of the care plan revealed the facility developed a care plan based on the patient ' s identified needs and the care plan includes approaches for treatment and services. The care plan however does not include approaches for care of the patient ' s surgical post- operative wound.

Review of the clinical record revealed Patient # 10 underwent an Open Reduction Internal Fixation of the left femur (ORIF) on 09/06/11. A physician order dated 09/06/11 documents " leave surgical dressing intact unless soiled " . This care approach for the surgical wound / incision is not documented or incorporated in the care plan. There are no further instructions for care of the surgical incised wound documented on the medical record.

Interview with RN # 1 was conducted on 11/02/11 at 11:33 AM. Registered Nurse # 1 stated post- operative care is dictated by the physician orders, and that most commonly wound care is provided on the second day after surgery and then daily.
Interview with the 5th floor Charge Nurse conducted on 11/03/11 at 10:25 AM revealed the facility does not have postoperative wound care policies and procedures, and the post-operative care is driven by physician orders. In addition the Charge Nurse stated, the facility has a Protocol to change surgical dressings on the second day post operatively and then daily. The Charge Nurse explained, nursing assessments includes incision/wound assessments and those assessments are to be done every shift. The Charge Nurse reviewed the electronic clinical record for Patient # 10 and stated the facility ' s protocol / practice for wound care is also determined by the type of surgical dressing. The Charge Nurse stated Patient # 10 had a dressing called " Island " or paper dressing, which according to the Protocol is to be changed on post- op day two and then to be changed daily.
The surveyor requested to review the Protocol and was informed there is no written Protocol. Nurses #1 and the Charge Nurse were interviewed and they both acknowledged the Protocol is to change surgical dressings on post-operative day two, unless the physician ordered a different treatment.

The facility failed to develop written standards of nursing practice and related policies and procedures to " define " and " describe " the scope and conduct of patient care provided by the nursing staff as it relates to post-operative incisional wound care.

Review of Patient # 10 clinical record revealed the delivery of care by nursing as follows:
Nurses Notes dated 09/06/11 through 09/08/11 reveals the surgical incision to the left femur was assessed and the first dressing change is documented to have been done on 09/08/11. Subsequent Nurses Notes dated 09/09/11 and 09/10/11 fail to substantiate the performance of wound assessments or dressing changes to the patient ' s left femur. Daily dressing changes to the surgical incision are documented from 09/11/11 thru 10/05/11 with the exception of 09/22/11 and 09/24/11.

The Nursing Shift Assessment dated 09/11/11 at 8:00 PM documents, " dressing change to left hip as family requested, " they were told it was not changed yet " . The Assessment also document another wound to the patient ' s left femur described as " skin tear " . The skin tear measured 2 centimeters in length and 2 centimeters in width. The assessment also notes wound site # 2 to the patient ' s left lower extremity. This wound is described as a skin tear that is partially granulated. The nurse also documented the physician was notified of both skin tears/wounds.


Physician ' s Order dated 09/11/11 documents the performance of a wound care consult. Skin Wound Management Protocol Order Sheet dated 09/12/11 documents as follows:
Skin tears and abrasions: Cleanse with Normal Saline and apply Safegel then cover with Mepilex border or Mepitel Dressing and Gauze. Change every other day. This entry is not marked off, indicating nursing acknowledgement, on the order sheet.
The entries checked off on the document are as follows:
? Reposition every two hours in bed and every 15-30 minutes when in chair. Seat cushion while in chair at all times. Offload heels to relieve pressure while in bed at all times.
? Suspected deep tissue injury to left heel and top of left foot. Off load area to relieve pressure at all times. Cleanse with saline apply Xeroform cover with dry gauze and Kerlix daily.
? The document also includes an order for nutritional consult.


Further review of the Nursing Shift Assessments and Nurses Notes failed to disclose wound care was provided for Patient # 10 in accordance with the spoken facility protocol (for the surgical incision wound) as per the charge nurse, or based on the specified physician orders for the patient ' s skin tears:
Skin Wound Management Protocol Order Sheet dated 09/12/11 documents as follows:
Skin tears and abrasions: Cleanse with Normal Saline and apply Safegel then cover with Mepilex border or Mepitel Dressing and Gauze. Change every other day. (This order is not marked off in the medical record ' s order sheet, indicating nursing acknowledgement).

The nurses documentation reflects the following:
Wound (skin tear) care to left heel was not provided on 09/14/11, 09/15/11, 09/16/11, 09/17/11, 09/18/11, 09/19/11, 09/20/11, 09/22/11, 09/24/11, 09/25/11, 09/26/11, 09/29/11, 09/30/11, 10/04/11 and 10/05/11.
Wound (skin tear) care to top of left foot was not provided on 09/16/11, 09/17/11, 09/18/11, 09/22/11, 09/24/11, 09/28/11, 10/04/11 and 10/05/11.

The Nurses Notes dated 09/21/11 documents the incision wound is necrotic, and another and new wound to the patient ' s left lower leg/left ankle was identified. The physician and surgeon were informed per the nurse ' s note. Pictures were taken and the dressing was changed.
A physician order dated 09/21/11 documents wound care with Xeroform to left ankle with 4x4 Kerlix daily.

Further review of the Nurses Notes failed to substantiate the provision of wound care, to the left ankle/lower leg wound, was rendered to Patient # 10 on 09/24/11, 10/03/11, 10/04/11 and 10/05/11.

In addition the clinical record contained a physician order dated 09/26/11for Santyl ointment to be applied to affected areas. The physician order did not identify wound location. Review of the Nurses Notes documented the Santyl ointment was applied to the left hip incision area.

Interview with the 5th floor Charge Nurse was conducted on 11/03/11 at 10:25 AM. The Charge Nurse reviewed the entire (all) electronic Nurse ' s Notes contained in the clinical record of patient #10. She stated she recalled Patient # 10, as the patient was in the unit for almost a month. The Charge Nurse stated the wound care order dated 09/12/11 " was only for the left top of the foot, not the heel. She acknowledged the order sheet documents treatment orders to both the heel and the top of the foot, but she added the heel was not open and there was no reason to do this dressing to the heel " . (The charge nurse ' s position is in direct conflict with the skin wound management protocol orders for skin tears dated 09/12/11).
The Charge Nurse reviewed the Nursing Assessments and acknowledged the discrepancies found and mentioned in this report above, relating to wound assessments and the treatment provided. The Charge Nurse stated the nurses are documenting the dressings were not performed and the assessments were deferred. The Charge Nurse stated some of the nurses documented the wound to the top of the foot twice and they failed to document the heel. The Charge Nurse was not able to provide written clarification of the wound orders dated on 09/12/11, nor clear and concise evidence of nursing personnel ' s adherence to the spoken standards of care (Protocol) or written physician ' s orders. The Charge Nurse stated the nurses follow physician orders for post-operative care, and the protocol is to change the dressing to the incision on post- operative day two and then daily. She stated the only exception would be for patients who had the Dermabond dressing or skin glue (a clear dressing that would stay in place until the patient is seen by the physician as an outpatient). The Charge Nurse was unable to locate and provide the facility ' s written protocols / standards that define and describe the approaches to be rendered in providing surgical incisional care, and as it relates to Patient # 10 a care plan that includes the approaches for care to be rendered for the incision wound was not established nor provided during the survey.

Interview with the Wound Care Nurse was conducted on 11/03/11 at 12:00 PM. The Wound Care Nurse stated the wound care order dated on 09//12/11 was written by one of the Wound Care Nurses. She stated the wound care was for both the heel and the top of the foot. The Wound Care Nurse stated, the floor nurses do the wound care but the Wound Care Nurses monitor the wound periodically. The Wound Care Nurse presented an electronic order dated 09/26/11 for Santyl ointment. She stated this order was written by the wound care physician. The Wound Care Nurse was not able to explain which wound was to receive this treatment. The physician order read "Santyl Ointment to affected areas".

Review of the policy titled Wound Care Assessment revealed nursing documentation should include the following: Daily skin assessments and treatment interventions and response to treatment.

The above described provision of care does not comply with the physician orders for wound care. The clinical record failed to substantiate the actions taken by nursing in providing care and services related to wound care is consistent with the medical practitioner ' s goals.