HospitalInspections.org

Based on document review and interview, the facility failed to ensure medical record (MR) documentation included orders for treatment of wounds in 1 (MR 1) of 10 MR's reviewed:

Findings include:

1. Review of Medical Staff Rules and Regulations, indicated on page 7: "5.4.1 All orders for medications and/or treatment for patients admitted to the Facility shall be in writing".

2. Review of patient 1's MR lacked documentation of physician orders for treatment of the patient's left big toe and right foot wounds and bruising to bilateral hands/feet.

3. On 9/27/18 at approximately 1300 hours, staff N1 (Director of Nursing) was interviewed and confirmed patient 1's MR lacked documentation of physician orders for wound treatment.

Based on document review and interview, the facility failed to ensure the medical record (MR) included documentation of daily assessments and treatment of wounds and fall risk assessments in 1 (MR 1) of 10 MR's reviewed:

Findings include:

1. Policy/procedure, Skin Assessment, revised/reviewed 8/16, indicated on page 2: "A nurse should document carefully the condition of any wounds the patient may have. Appearance of the wound should include information about whether it appears infected, size of wound or skin tear, warm to touch, location, edematous, sutures intact, etc. If the patient has a decubitus, it should be given an approximate stage level. The colors appearing in bruises also should be documented as this is an indication of age in bruising if any allegations of abuse or injury are made".

2. Policy/procedure, Wound Irrigation, revised/reviewed 8/16, indicated: "Wound care and irrigation shall be performed by a licensed nurse as ordered by the physician to clean the wound and prevent infection. Document procedure, including patient teaching and patient response in the medical record".

3. Policy/procedure, Fall Risk, revised/reviewed 2/18 indicated on page 3: "Reassess the patient daily to determine if the risk of falls has changed".

4. Review of patient 1's MR lacked documentation of skin assessments and treatment of the patient's left big toe and right foot wounds and lacked documentation of assessments of bruising to bilateral hands/feet. Review of patient 1's MR also lacked documentation of daily assessment of patient's risk for falls and implementation of fall risk interventions.

5. On 9/27/18 at approximately 1300 hours, staff N1 (Director of Nursing) was interviewed and confirmed patient 1's MR lacked documentation per nursing staff of wound assessments and lacked documentation of daily falls risk assessment and implementation of precautions.