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Based on observations, clinical record review and staff interviews the nursing staff failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 5 sampled patients (Patient # 5) as evidenced by failure to follow physician orders for wound care.


The findings include:


Clinical record review on 03/18/14 revealed Patient # 5 was admitted to the facility on 01/02/14 with an infected wound to the left hip, redness to sacrum and bilateral heels; and an old scar to the right hip.

1) Physician's Orders dated 01/03/14 documents Negative Pressure Wound Therapy (Wound VAC) to left hip, continuous suction at 125 mmHg, change on Mondays, Wednesday and Fridays.

Review of the Nursing staff documented Assessments, and the Plastic Surgeon Progress Notes dated 01/03/14 thru 03/14/14 failed to provide evidence of dressing changes to the left hip on 01/22/14, 01/27/14, 02/03/14, 02/17/14 and 02/26/14.

Interview with The Charge Nurse on 03/18/14 at 2:45 PM revealed the Wound VAC changes are done by the physician (plastic surgeon) or by the floor nurse. The Charge Nurse reviewed Patient #5's electronic record, and physician progress notes and acknowledged there is no documentation to substantiate the wound VAC dressing is being performed on the identified days, per physician's orders.

Interview with the Director of The Telemetry/Medical Surgical Unit on 03/19/14 at approximately 2 PM revealed there is no further evidence the wound care was provided on the identified days as ordered. The Director acknowledged there is no documentation of the treatments being provided.


2) Physician's Order dated 01/09/14 documents "Wash area with soap and water, pat dry, apply Duoderm every five days and as needed to the right hip. Change immediately if edges roll or soiled" .
Review of the nursing staff Assessments dated 01/09/14 thru 03/17/14 revealed the Duoderm ordered every five days, was not changed from 01/09/14/ thru 01/28/14; 02/01/14 thru 02/07/14 and from 02/13/14 thru 03/13/14.

Further review of Patient #5's record disclosed notes documenting concerns regarding the provision of wound care.
Wound Care Notes dated 01/17/14 documents "Duoderm observed to the right hip dated 01/09/14" (8 days duration for the dressing).
Wound Care Notes dated 01/25/14 documents "Duoderm observed to the right hip dated 01/17/14" (8 days duration for the dressing).
The notes indicate the Duoderm was not changed every five days as ordered.

Interview with The Director of The Telemetry/Medical Surgical Unit conducted on 03/19/14 at approximately 2 PM revealed the provision of wound care is documented on the shift assessments, skin or incisions and wounds section. The Director reviewed Patient #5's electronic record and acknowledged there is no evidence the Duoderm was changed on the time frames per the physician's order.


Further review of the record revealed a Wound Care Note indicating Patient # 5 developed additional wounds on 01/17/14. The Left heel deteriorated to a stage II; another stage II developed to the Lateral aspect of the fifth metatarsal head on the right foot and the coccyx wound deteriorated to Unstageable due to yellow non- viable tissue and hemorrhagic bed.


3) Physician's Order dated 01/25/14 documents Xenaderm Ointment, apply to clean dry reddened skin three times a day and as needed to the Gluteal, Perineum and Groin areas. The order was updated on 02/25/14 and on 03/16/14 to read: Xenaderm Ointment, apply to clean dry reddened skin twice a day and as needed to the Gluteal, Perineum and Groin areas.
Interview with The Charge Nurse conducted on 03/18/14 at 2:45 PM revealed Xenaderm Ointment is provided by the pharmacy and the administration is documented on the Medication Administration Record (MAR).
Upon request, the pharmacy provided a summary of the Medication Administration Record for Patient # 5. The Xenaderm Ointment administration is not documented on 01/25/14 thru 01/30/14; 02/01/14 thru 02/11/14; 02/14/14 thru 03/17/14.

Interview with The Director of The Telemetry/Medical Surgical Unit, 03/19/14 at approximately 2 PM, revealed the electronic MARs document next to the order for the Xenaderm Ointment "Duplicate Task". The Director explained Patient # 5 has orders for the Xenaderm Ointment scheduled twice a day and also as needed; the electronic record requires the nurse to identify the order and choose the routine or PRN administration. There is no evidence the routine administration was given; it is likely the nurse read the order as PRN (as needed), per the director.


4) Physician's Order dated 02/25/14 documents "Lateral right heel. Cleanse with Normal Saline, cover with small piece of Xeroform gauze, then apply gauze and wrap lightly with kling and secure with tape daily."
Review of the Nursing Shift Assessments dated 02/27/14; 03/01/14; 03/04/14 and 03/06/14 thru 03/15/14 revealed no evidence the treatment was provided.
Interview with The Charge Nurse conducted on 03/18/14 at 2:45 PM revealed the provision of wound care is documented on the shift assessment under the skin or incisions and wounds section. The Charge Nurse was not able to provide evidence of the daily dressing changes on the days identified above.
Observation conducted on 03/19/14 at 9:45 AM while accompanied by the Wound Care Nurse revealed Patient # 5 had a dressing to the right heel dated 03/17/14.


5) Physician's Order dated 02/25/14 documents "Lateral 5th metatarsal head of the right foot, Cleanse with Normal Saline, paint lightly with betadine swab, cover with dry gauze, and wrap lightly with kling and secure with tape daily".
Review of the Nursing Shift Assessments dated 02/26/14; 02/27/14; 03/01/14; 03/04/14 and 03/06/14 thru 03/14/14 revealed no evidence the treatment was provided.
Observation conducted on 03/19/14 at 9:45 AM while accompanied by the Wound Care Nurse revealed Patient # 5 had dressing to the right foot dated 03/17/14, indicating the dressing was done 2 days prior, and not daily per physician's order.

Interview with The Director of The Telemetry/Medical Surgical Unit conducted on 03/19/14 at approximately 2 PM revealed the provision of wound care is documented on the shift assessments, skin or incisions and wounds section. The Director reviewed the electronic record and acknowledged there is no evidence the Duoderm was changed on the time frames identified above.


6) Physician's Order dated 03/16/14 documents "Lateral Left Leg, cleanse with normal saline, cover with small piece of Xeroform gauze daily, then dry gauze and wrap with kling and secure with tape".
Interview with The Nurse Manager for Wound Care and Diabetes Program on 03/19/14 at 9:07 AM, revealed she has identified some concerns regarding the provision and documentation of wound care. The primary nurses are made aware every time she has a concern, and the facility administration recently had a mock deposition in-service regarding proper documentation of wound care.
Observation conducted on 03/19/14 at 9:45 AM while accompanied by the Wound Care Nurse revealed Patient # 5 had dressing to the left leg dated 03/17/14. The Nurse acknowledged the dressing change to the area is to be done daily.


Facility policy titled "Skin Integrity Assessment & Protocol for Pressure Ulcer prevention and Skin Impaired Skin", last revised 09/13 documents The policy is to maintain the patient's skin integrity by assessing risk, preventing breakdown, treating wounds and promoting healing to the greatest extent possible through the patient's hospitalization. All pressure ulcers that are identified upon admission will be assessed and treated. A wound care consult will be initiated. If impairment of skin integrity is found during the hospitalization, then a photo will be taken of the impaired areas and noted on the record. The primary nurse will implement the initial treatment per the protocol for all wounds. Documentation may include, but is not limited to: Wound number, date and time, size, dressing applied and initials and signatures.

Based on observations, clinical record review and staff interviews the nursing staff failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 5 sampled patients (Patient # 5) as evidenced by failure to follow physician orders for wound care.


The findings include:


Clinical record review on 03/18/14 revealed Patient # 5 was admitted to the facility on 01/02/14 with an infected wound to the left hip, redness to sacrum and bilateral heels; and an old scar to the right hip.

1) Physician's Orders dated 01/03/14 documents Negative Pressure Wound Therapy (Wound VAC) to left hip, continuous suction at 125 mmHg, change on Mondays, Wednesday and Fridays.

Review of the Nursing staff documented Assessments, and the Plastic Surgeon Progress Notes dated 01/03/14 thru 03/14/14 failed to provide evidence of dressing changes to the left hip on 01/22/14, 01/27/14, 02/03/14, 02/17/14 and 02/26/14.

Interview with The Charge Nurse on 03/18/14 at 2:45 PM revealed the Wound VAC changes are done by the physician (plastic surgeon) or by the floor nurse. The Charge Nurse reviewed Patient #5's electronic record, and physician progress notes and acknowledged there is no documentation to substantiate the wound VAC dressing is being performed on the identified days, per physician's orders.

Interview with the Director of The Telemetry/Medical Surgical Unit on 03/19/14 at approximately 2 PM revealed there is no further evidence the wound care was provided on the identified days as ordered. The Director acknowledged there is no documentation of the treatments being provided.


2) Physician's Order dated 01/09/14 documents "Wash area with soap and water, pat dry, apply Duoderm every five days and as needed to the right hip. Change immediately if edges roll or soiled" .
Review of the nursing staff Assessments dated 01/09/14 thru 03/17/14 revealed the Duoderm ordered every five days, was not changed from 01/09/14/ thru 01/28/14; 02/01/14 thru 02/07/14 and from 02/13/14 thru 03/13/14.

Further review of Patient #5's record disclosed notes documenting concerns regarding the provision of wound care.
Wound Care Notes dated 01/17/14 documents "Duoderm observed to the right hip dated 01/09/14" (8 days duration for the dressing).
Wound Care Notes dated 01/25/14 documents "Duoderm observed to the right hip dated 01/17/14" (8 days duration for the dressing).
The notes indicate the Duoderm was not changed every five days as ordered.

Interview with The Director of The Telemetry/Medical Surgical Unit conducted on 03/19/14 at approximately 2 PM revealed the provision of wound care is documented on the shift assessments, skin or incisions and wounds section. The Director reviewed Patient #5's electronic record and acknowledged there is no evidence the Duoderm was changed on the time frames per the physician's order.


Further review of the record revealed a Wound Care Note indicating Patient # 5 developed additional wounds on 01/17/14. The Left heel deteriorated to a stage II; another stage II developed to the Lateral aspect of the fifth metatarsal head on the right foot and the coccyx wound deteriorated to Unstageable due to yellow non- viable tissue and hemorrhagic bed.


3) Physician's Order dated 01/25/14 documents Xenaderm Ointment, apply to clean dry reddened skin three times a day and as needed to the Gluteal, Perineum and Groin areas. The order was updated on 02/25/14 and on 03/16/14 to read: Xenaderm Ointment, apply to clean dry reddened skin twice a day and as needed to the Gluteal, Perineum and Groin areas.
Interview with The Charge Nurse conducted on 03/18/14 at 2:45 PM revealed Xenaderm Ointment is provided by the pharmacy and the administration is documented on the Medication Administration Record (MAR).
Upon request, the pharmacy provided a summary of the Medication Administration Record for Patient # 5. The Xenaderm Ointment administration is not documented on 01/25/14 thru 01/30/14; 02/01/14 thru 02/11/14; 02/14/14 thru 03/17/14.

Interview with The Director of The Telemetry/Medical Surgical Unit, 03/19/14 at approximately 2 PM, revealed the electronic MARs document next to the order for the Xenaderm Ointment "Duplicate Task". The Director explained Patient # 5 has orders for the Xenaderm Ointment scheduled twice a day and also as needed; the electronic record requires the nurse to identify the order and choose the routine or PRN administration. There is no evidence the routine administration was given; it is likely the nurse read the order as PRN (as needed), per the director.


4) Physician's Order dated 02/25/14 documents "Lateral right heel. Cleanse with Normal Saline, cover with small piece of Xeroform gauze, then apply gauze and wrap lightly with kling and secure with tape daily."
Review of the Nursing Shift Assessments dated 02/27/14; 03/01/14; 03/04/14 and 03/06/14 thru 03/15/14 revealed no evidence the treatment was provided.
Interview with The Charge Nurse conducted on 03/18/14 at 2:45 PM revealed the provision of wound care is documented on the shift assessment under the skin or incisions and wounds section. The Charge Nurse was not able to provide evidence of the daily dressing changes on the days identified above.
Observation conducted on 03/19/14 at 9:45 AM while accompanied by the Wound Care Nurse revealed Patient # 5 had a dressing to the right heel dated 03/17/14.


5) Physician's Order dated 02/25/14 documents "Lateral 5th metatarsal head of the right foot, Cleanse with Normal Saline, paint lightly with betadine swab, cover with dry gauze, and wrap lightly with kling and secure with tape daily".
Review of the Nursing Shift Assessments dated 02/26/14; 02/27/14; 03/01/14; 03/04/14 and 03/06/14 thru 03/14/14 revealed no evidence the treatment was provided.
Observation conducted on 03/19/14 at 9:45 AM while accompanied by the Wound Care Nurse revealed Patient # 5 had dressing to the right foot dated 03/17/14, indicating the dressing was done 2 days prior, and not daily per physician's order.

Interview with The Director of The Telemetry/Medical Surgical Unit conducted on 03/19/14 at approximately 2 PM revealed the provision of wound care is documented on the shift assessments, skin or incisions and wounds section. The Director reviewed the electronic record and acknowledged there is no evidence the Duoderm was changed on the time frames identified above.


6) Physician's Order dated 03/16/14 documents "Lateral Left Leg, cleanse with normal saline, cover with small piece of Xeroform gauze daily, then dry gauze and wrap with kling and secure with tape".
Interview with The Nurse Manager for Wound Care and Diabetes Program on 03/19/14 at 9:07 AM, revealed she has identified some concerns regarding the provision and documentation of wound care. The primary nurses are made aware every time she has a concern, and the facility administration recently had a mock deposition in-service regarding proper documentation of wound care.
Observation conducted on 03/19/14 at 9:45 AM while accompanied by the Wound Care Nurse revealed Patient # 5 had dressing to the left leg dated 03/17/14. The Nurse acknowledged the dressing change to the area is to be done daily.


Facility policy titled "Skin Integrity Assessment & Protocol for Pressure Ulcer prevention and Skin Impaired Skin", last revised 09/13 documents The policy is to maintain the patient's skin integrity by assessing risk, preventing breakdown, treating wounds and promoting healing to the greatest extent possible through the patient's hospitalization. All pressure ulcers that are identified upon admission will be assessed and treated. A wound care consult will be initiated. If impairment of skin integrity is found during the hospitalization, then a photo will be taken of the impaired areas and noted on the record. The primary nurse will implement the initial treatment per the protocol for all wounds. Documentation may include, but is not limited to: Wound number, date and time, size, dressing applied and initials and signatures.