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Based on hospital policy review, medical record review, family, physician, and staff interviews, the hospital nursing staff failed to ensure wound care was provided per physician orders for 1 of 2 sampled patients receiving wound care (#5).

Findings include:

Review of hospital policy on 09/30/2015 revealed "Skin Assessment/Pressure Ulcer Prevention and Treatment" revised 02/2014. Review of the policy revealed "If a pressure ulcer is present, the nurse needs to stage the ulcer so appropriate treatment can be started. . . Wound Care - Refer to: Convatec Solutions Algorithms for Wound Care and Further Skin Recommendations. . . Stage IV - full thickness tissue loss with exposed bone, tendons or muscle . . . GOAL - Obtain clean wound bed. Absorb excess moisture. . . Obtain an appropriate stage order form physician."

Review of Convatec Solutions Algorithms for Wound Care and Further Skin Recommendations on 09/30/2015 revealed care for Stage IV Pressure Ulcer as "Clean wound bed with wound cleanser. Apply Aquacel (brand name for wound dressing with absorption properties) to wound bed and any undermining or tunneling. Cover with Duoderm (brand name for occlusive dressing)."

Closed medical record review for Patient #5 revealed a hospital admission date of 06/18/2015 via the emergency department (ED) with diagnoses of Septic Shock (blood infection), Early Multisystem Organ Failure, Decreased Potassium, Decreased Magnesium, Low Platelet Count, Urinary Tract Infection, Blood Cultures times two showing staph (bacteria) sensitive to Levaquin and Vancomycin (antibiotics), Wound Culture demonstrating staph, Decubitus (open wound) and Spina Bifida (birth defect in which there is an opening in the spinal cord). Review of lab findings for the right groin wound culture and sensitivity collected on 06/15/2015 (previous ED visit) revealed a growth of Staphylococcus Aureus (bacteria that was not resistant to antibiotics). Review of physician's order for wound care revealed "06/18/2015 BID (two times per day) 08, 20 (0800 and 2000) Begin Wound Care Protocol using Convatec Solutions Algorithm for wound care of: Stage of Wound: Stage IV Pressure Ulcer." Continued review revealed the order was entered and signed by MD #3 on 06/18/2015 at 1623 and acknowledged by RN #1 on 06/18/2015 at 1901.

Review of nursing progress notes, medication administration record and interdisciplinary care plan for 06/18/2015 through 06/25/2015 revealed Patient #5 had a right groin Stage IV pressure ulcer that was present at time of admission. Continued review revealed wound care was conducted five times during the hospital admission by packing the wound with Iodoform (medicated long strip of gauze) covered with a feminine hygiene pad. Continued review revealed no evidence the wound was cleansed and dressed per the physician's order for 14 of 14 times the wound dressing was ordered to be changed.

Interview on 10/01/2015 at 0940 with RN #1 revealed Patient # 5's family requested the dressing to be changed using the Iodoform packing covered with a feminine hygiene pad. The interview revealed the wound had a large amount of drainage and the feminine hygiene pad absorbed the drainage. The interview revealed the family was the primary caregivers at home and had been caring for the wound for several years. The interview revealed the family stayed at the bedside during the entire hospitalization. "We pretty much did what the [family members] requested." RN #1 did not remember a physician order for the wound to be packed with Iodoform gauze.

Telephone interview with Patient #5's family member on 09/30/2015 at 0857 revealed the family was responsible for wound care at home. The interview revealed the family did not use Iodoform covered with a feminine hygiene pad for wound care at home. The interview revealed the family member was not aware of a physician's order to pack the wound with Iodoform and cover with a feminine hygiene pad.

Interview on 10/01/2015 at 1130 with MD #1 revealed the right groin wound for Patient #5 was a chronic wound with a large amount of drainage when the patient was evaluated in the ED on 06/15/2015.

Interview on 10/01/2015 at 0930 with Administrative Staff #2 revealed wound care was not performed per the physician's order.

NC00110007

Based on review of facility policy and procedures, medical records (MR), staff interviews the facility failed to retain the original record after making an amendment in 1 of 6 (Patient #7) discharge summaries reviewed.
The findings include:
Review of the facility's "Health Information Management Department Policies" last reviewed 10/2013 presented by administrative staff on 10/01/2015 revealed "Errors and Corrections: Errors in the medical record shall be corrected by drawing a single line through the entry in such a manner that the erroneous entry is not obscured and writing "error". Corrections may not be accomplished by erasure, page replacement, correction fluid, or any other means, which obscure the original entry. All corrections shall be signed/initialed and dated...Any cross-outs with or without re-entries should be noted as "error", dated and initialed..."
Review of the facility's "Documentation in the Medical Record, D-50-A24" policy last reviewed 08/2012 presented by administrative staff on 09/30/2015 revealed "Incorrect enteries in Meditech: 1. If an incorrect entry is documented, the entry should be "Edited" or "Undone" depending on the nature of the documenation. Patient documenation can only be Edited or Undone by the staff who made the entry...3. If the entry is "Undone, "a corrected entry must be entered. 4. Undone information is not erased from the system but is recorded as an Edited or Undone entry for auditing pouposes..."
Closed MR review for Patient #7 revealed a 76 year old male presented to the hospital's Emergency Department (ED) on 01/31/2015 at 2330 via emergency medical services (EMS). Review of the patient assessment completed in the hospital's Emergency Department (ED) dated and timed 01/31/2015 at 2330 by MD #4 revealed the patient presented from a skilled nursing facility (SNF) where he/she was receiving rehabilitative services following protracted (lasting for a long time) hospital stays at two separate facilities for treatment of pancreatitis (inflammation of the pancreas) and pneumonia. Review revealed a chest x-ray (CXR: noninvasive test that creates pictures of the structures inside the chest) was performed that showed "pleural scarring (thickening of the lining of the lung)..." Review revealed a computed tomography (CT) scan (diagnostic study that produces a 3-dimensional image) of the abdomen was also performed with a "Pancreatic pseudocyst (fluid-filled sac)" identified. Review revealed a conversation with MD #5 (general surgeon) who "indicated he will be willing to consult on the patient..."

Review of the CT scan of the abdomen findings dated 01/31/2015 revealed "There is a large... fluid collection surrounding the pancreas..." Review revealed the fluid collection measured "at least 13 cm (centimeter: a metric unit of length) in diameter." Review revealed the fluid collection "surrounds the superior mesenteric vein (blood vessel that drains blood from the small intestine) and may contribute to some narrowing..." Review revealed "IMPRESSION: 1. RELATIVELY LARGE PERIPANCREATIC PSEUDOCYST WHICH LIKELY CONTRIBUTES TO NARROWING BUT NOT OCCLUSION OF THE SUPERIOR MESENTERIC VEIN..."

Review of the History and Physical dated and timed 02/01/2015 at 0011 by MD #6 revealed the patient presented to the hospital's ED for evaluation of "progressively getting weaker with generalized lethargy (lack of energy)." Review revealed the patient experienced nausea, vomiting, weakness, lethargy, and "episodes of fever of 101" prior to presentation to the ED. Review revealed a CT scan "showed a large pancreatic pseudocyst of 13 cm, with narrowing of the superior mesenteric vessel..."

Review of the consultation by MD #5 dated and timed 02/01/2015 at 1048 revealed "REASON FOR CONSULTATION: Pancreatic pseudocyst..." Review revealed "I was asked to see him regarding his pancreatic pseudocyst..." Review revealed "ANALYSIS AND PLAN: ...On the CT scan, he does have a pseudocyst, but this needs to be treated conservatively (not extreme or drastic), as this measures a maximum diameter of 13 cm..., but I do not think this is amenable (capable of being acted upon) for ... drainage at this time. We will have to wait and see how well it is doing in about 3 weeks to see if his collection has resolved or not..." Review revealed "At this point, there is no evidence of any necrotizing pancreatitis (death of tissue in and around the pancreas) that would require any surgical intervention..."

Review of MD #3 progress note (PN) dated and timed 02/01/2015 at 1429 revealed "...ASSESSMENT: 4. Recent diagnosis of pancreatic pseudocyst..." Review of MD #3 PN dated and timed 02/02/2015 at 1742 revealed "ASSESSMENT: 3. Pancreatitis with pseudocyst..." Review of MD #2 PN dated and timed 02/03/2015 at 1754 revealed "ASSESSMENT: 3. Pancreatic pseudocyst. The patient has been seen and evaluated by Dr. ____ MD #5, who has chosen to treat the patient conservatively, and repeat his CAT scan in another few weeks.."

Review of MD #2 dated and timed 02/04/2014 at 1326 on 09/29/2015 revealed "HISTORY OF PRESENT ILLNESS: "...He was found to have a pancreatic pseudocyst...and evaluation of his pseudocyst...HOSPITAL COURSE:... The patient has been evaluated by Dr. ____ MD #5 of general surgery regarding his pancreatitis and his pseudocyst. The consensus is to treat the patient conservatively. The pseudocyst measures in diameter 13 cm...Advice is to repeat a CAT scan in 3-4 weeks and see if this collection has resolved or increased in size. No evidence of necrotizing pancreatitis...DISCHARGE DIAGNOSES: 1. Acute pancreatitis resolved with no pseudocyst..." Review of same on 10/01/2015 revealed "DISCHARGE DIAGNOSES: 1. Acute pancreatitis resolved with pseudocyst... cor: 9/30/15 ljm
Interview on 10/01/2015 at 0945 with MD #2 revealed "He (Patient #7) did have a pseudocyst." Interview revealed "I can't say at this point what happened. Whether it was in the transcription or dictation area, I don't know." Interview revealed for someone who "doesn't know this patient and looks at this (discrepancy in discharge summary and other medical record documentation), I'm gonna say "What" If there's a CT scan, consultation, and summary from the consultation saying there's a pseudocyst, there's a pseudocyst." Interview revealed, "It's an error." Interview revealed, "I need to get with Health Information Management (HIM) and correct it."

Interview on 10/01/2015 at 1405 with the hospital's Director of HIM (HIM #1) and Chief Information Officer (CIO #1) revealed Physician #2 came to the HIM department and "crossed thru the word "No" and said it's "with pseudocyst." Interview revealed "I like to show who modified the original document and when. It isn't a requirement, it's something I have chosen to do." Interview revealed the orginial documentation is not retained once amendments have been made and the amended document is not indicated as such.