HospitalInspections.org

Based on record review and interview the facility failed to provide documentation that Emergency Department(ED) patients received notification of Patient Rights on #2 thru #11 charts reviewed.

Findings: Emergency Department records were reviewed on 10/7/2010 at 9:00 am in the conference room.

Review of Emergency Department records for patient #2, #3, #4, #5, #6, #7, #8, #9, #10,and #11 revealed no documentation that patient rights were received by patient on admission.


Interview with Staff # 1 on 10/7/2010 at 10:00 am in the conference room confirmed that the ED patients had no documentation on charts that they were given copy of patient rights.

Based on record review and interview the facility failed to follow the hospital policy on assessment of a wound care patient.

Reviewed policy # IC-001.019 Wound Assessment and Protocols, revised 03/2009;

1.0 Purpose
1.1 To identify upon admission patients with pressure ulcers or the
potential to develop pressure ulcers.

2.0 Policy
2.1 All patients upon admissions and discharge will have a wound
assessment performed.

3.0 Procedure
3.3 If the patient has a pressure ulcers document findings on the " Wound documentation Form " on admission.

3.3.1 The status of pressure ulcers shall be assessed every Sunday
A.M. utilizing this form.

3.4 The treatment protocols are part of the physician ' s admitting .
orders and if not checked the physician should be notified of findings.

3.4.1 Place appropriate protocol on chart under Dr ' s Orders.
3.4.2 Have the physician sign and complete (if necessary) on next
visit.

In reviewing patient record #1 the Wound Assessment Worksheet was incomplete, the back page of the form was blank which gives a description of the wound. No evidence that the wound was re-assessed on Sunday A.M. per policy.

In reviewing patient record #1 no evidence of Stage 1 Pressure Ulcer Treatment Protocol found in the chart.

In reviewing patient record #1 physician's orders, no evidence found for any type of wound care.

In reviewing patient record #1 patient was turned every 2 hours, 2 of 6 days while hospitalized. On 9/6, 9/7, 9/8, and 9/9, no evidence found that patient was turned every 2 hours.

In reviewing patient record #1 in the nursing documentation they used a product called excuderm, no order found for that product in the patient record.

In reviewing patient record #1 in the nursing patient assessment dated 09/05/10 on the 7 pm shift the nurse documented Excuderm to lower back-reddened blister without drainage. No evidence found in the record where physician was notified of wound change, or physicians's order/wound protocol for Excuderm.

In reviewing patient record #1 it revealed in the nursing documentation dated 09/06/10 at 12:35 pm the sitter notified the nurse caring for patient #1 that patient has red areas to her bottom that she had noticed during diaper change. Patient care nurse notified Charge nurse and she notified physician, no orders received from physician for wound care.

Interviewed Medical/Surgical Director #6 on 10/07/2010 at 10:00 a.m. in the conference room, she confirmed that nursing documentation was incomplete on the wound assessment worksheet, the patient had not been turned, and Wound protocol had not been used per the policy # IC-001.019 Wound Assessment and Protocols.