HospitalInspections.org

Based on document review and interview, the nurse executive failed to ensure that nursing followed wound care orders for 1 of 5 wound care patients (Pt. #1).

Findings:
1. Review of the medical record for patient #1, admitted on 6/24/15, indicated:
a. A wound care consult on 6/25/15 at 11:49 AM had documentation that the "Plan" was for "left lateral foot painted with betadine, left open to air. Will order daily...".
b. Notations in the medical record on 6/26/15 and 6/28/15 lacked any documentation by nursing staff that betadine was applied to the left lateral foot, as ordered by wound care staff.

2. At 8:35 AM on 9/16/15, interview with staff member #50, the quality resources and risk manager, indicated that after thorough review of the medical record for patient #1, there is no documentation of wound care to the left lateral foot for the dates of 6/26/15 and 6/28/15, as ordered by the wound care nurse.