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Based on record review and interview the nursing staff failed to notify the physician in a timely manner that the patient had a wound on admission and required wound care orders and wound care services for 1 of 2 patients (#1) who had wounds on Adamson to the facility.


The findings included:

Review of the clinical record of patient #1 revealed that the patient was admitted to the facility on 6/24/11 through the Emergency Room (ER) from an Assisted Living Facility (ALF). The patient ' s history included a dementia, Parkinson ' s disease, depression and high cholesterol. The patient was admitted with septic shock, acute renal failure and acute respiratory failure. On the initial nurses notes on 6/24/11 the nurse documented that the patient had a stage II decubitus on the buttocks. The attending physician documented a history and physical on admission that failed to identify any skin abnormalities. Consult with the infectious disease physician included that the patient may have an underlying occult abscess or infection; the consult with the pulmonologist reported that the patient had an elevated white cell count, which indicates possible infection; consult with the urologist reported that the patient had a fever of 103 degrees and a Foley catheter was placed by the physician; consult with the nephrologist documented that the patient was septic. Apparently none of the physicians examined the patient and found the decubitus ulcers on the coccyx and sacrum. On 6/25/11 the nurses wrote that the patient had a stage II decubitus on the sacrum. The nurse covered the decubitus with Vaseline gauze and a dressing. (without a physicians order) On 6/26/11 the nurse wrote that the sacral decubitus was clean and dry. On 6/28/11 the nurses wrote that there was a dressing to the coccyx. (without a physicians order) Review of the physician order sheets confirmed that the first order for wound care was written on 6/28/11. There was no documentation in the physician ' s progress notes that identified any skin care issue. The ' present on admission ' form was placed with the progress notes with the assessment of the wound and dated on 6/24/11 by the nurse. 6/24/11 was a Friday and the wound care team was not notified until Monday 6/27/11. The nurses treated the wound without orders over the weekend and failed to request a wound care order from any of the physicians treating the patient for 3 days. The physicians did not acknowledge the ' present on admission ' form until the order on 6/28/11 and the signature on 6/29/11. The wound care nurse conducted a consult on the patient on 6/28/11 and ordered the wounds on the sacrum, buttocks and left lower arm to be treated with Silvadene cream, Telfa and dry dressing daily. The nurse ' s notes and the medication administration record documented the wound care daily from 6/28/11 to discharge on 7/1/11. The patient was returned to the ALF with home health care for the wound.

Interview and policy review with the director of rehab and wound care on 8/29/11 at 11 am revealed that the Medical Executive Committee (MEC) has approved a ' protocol ' for wound care and 1 RN who is certified in wound care and 2 RN ' s that have also been given competencies for wound care and are seeking certification. Review of the current facility policy for Skin Integrity Assessment and Protocol for Pressure Ulcer Prevention and Impaired Skin revealed that a skin integrity assessment will be completed upon admission. All pressure ulcers that are identified on admission will be documented on the ' present on admission ' form and the form will be placed with the physician ' s progress section to be signed by the physician. The physician then orders the wound care nurse to conduct a consultation. Review of the current policy for Inpatient Nursing Consultation revealed that once a wound care consult is ordered by the physician, the wound care nurse will have the authority to write orders for wound care treatment.

Based on record review and interview the nursing staff failed to notify the physician in a timely manner that the patient had a wound on admission and required wound care orders and wound care services for 1 of 2 patients (#1) who had wounds on Adamson to the facility.


The findings included:

Review of the clinical record of patient #1 revealed that the patient was admitted to the facility on 6/24/11 through the Emergency Room (ER) from an Assisted Living Facility (ALF). The patient ' s history included a dementia, Parkinson ' s disease, depression and high cholesterol. The patient was admitted with septic shock, acute renal failure and acute respiratory failure. On the initial nurses notes on 6/24/11 the nurse documented that the patient had a stage II decubitus on the buttocks. The attending physician documented a history and physical on admission that failed to identify any skin abnormalities. Consult with the infectious disease physician included that the patient may have an underlying occult abscess or infection; the consult with the pulmonologist reported that the patient had an elevated white cell count, which indicates possible infection; consult with the urologist reported that the patient had a fever of 103 degrees and a Foley catheter was placed by the physician; consult with the nephrologist documented that the patient was septic. Apparently none of the physicians examined the patient and found the decubitus ulcers on the coccyx and sacrum. On 6/25/11 the nurses wrote that the patient had a stage II decubitus on the sacrum. The nurse covered the decubitus with Vaseline gauze and a dressing. (without a physicians order) On 6/26/11 the nurse wrote that the sacral decubitus was clean and dry. On 6/28/11 the nurses wrote that there was a dressing to the coccyx. (without a physicians order) Review of the physician order sheets confirmed that the first order for wound care was written on 6/28/11. There was no documentation in the physician ' s progress notes that identified any skin care issue. The ' present on admission ' form was placed with the progress notes with the assessment of the wound and dated on 6/24/11 by the nurse. 6/24/11 was a Friday and the wound care team was not notified until Monday 6/27/11. The nurses treated the wound without orders over the weekend and failed to request a wound care order from any of the physicians treating the patient for 3 days. The physicians did not acknowledge the ' present on admission ' form until the order on 6/28/11 and the signature on 6/29/11. The wound care nurse conducted a consult on the patient on 6/28/11 and ordered the wounds on the sacrum, buttocks and left lower arm to be treated with Silvadene cream, Telfa and dry dressing daily. The nurse ' s notes and the medication administration record documented the wound care daily from 6/28/11 to discharge on 7/1/11. The patient was returned to the ALF with home health care for the wound.

Interview and policy review with the director of rehab and wound care on 8/29/11 at 11 am revealed that the Medical Executive Committee (MEC) has approved a ' protocol ' for wound care and 1 RN who is certified in wound care and 2 RN ' s that have also been given competencies for wound care and are seeking certification. Review of the current facility policy for Skin Integrity Assessment and Protocol for Pressure Ulcer Prevention and Impaired Skin revealed that a skin integrity assessment will be completed upon admission. All pressure ulcers that are identified on admission will be documented on the ' present on admission ' form and the form will be placed with the physician ' s progress section to be signed by the physician. The physician then orders the wound care nurse to conduct a consultation. Review of the current policy for Inpatient Nursing Consultation revealed that once a wound care consult is ordered by the physician, the wound care nurse will have the authority to write orders for wound care treatment.