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A. Based on review of Hospital documents and interview, it was determined that, in 3 of 10 (Pt #4, Pt #5, & Pt #10) clinical records reviewed, the Hospital failed to ensure adherence to Hospital practice regarding specific wound and skin care as ordered.

Findings include:

1. Hospital policy entitled, "Skin Care Prevention Protocol " , (reviewed 10/11) required "Procedure C : The Wound Care Clinicians performs skin assessment on patients with 48 hours of admission for skin breakdown, and orders specific wound and skin care as needed".

2. The clinical record of Pt #4 was reviewed on 12/26/12 at approximately 11:00 AM. Pt #4 was a 58 year old female admitted on 11/30/12 with diagnoses of Osteomyelitis and Cellulitis in Sacrum secondary to sacral decubitus stage IV, Schizophrenia and Schizoaffective Disorder and Panic Attacks, Hyperlipidemia, and Anemia. Pt #4's clinical record contained wound care orders dated 12/1/12 that required the following: right ischium to be irrigated and Santyl applied daily, Hydrogel dressing applied to right lateral malleolus daily, Santyl applied to left heel daily. The clinical record lacked documentation that the wound care was performed on 12/2/12 and 12/3/12.

3. Pt #5's clinical record was reviewed on 12/26/12 at approximately 11:00 AM. Pt #5 was 62 year old female admitted on 12/13/12 with diagnoses of Acute Renal Failure, Infection & Inflammatory Reaction due to Vascular Device, Diabetes, ventilator dependent and wound care. Pt #5's clinical record contained wound care orders for the following: right lower quadrant abdomen -apply Maxorb with Microfoam tape daily, left lower quadrant of mid abdomen - wet to dry Kerlix every shift and as needed; right thoracic and left chest- apply Optifoam daily at left above the knee incision line - apply dry gauze with abdominal pad every shift and as needed. The clinical record lacked documentation on 12/14/12 and 12/15/12 that the left chest and left above the knee dressings were changed every shift as ordered.

4. Pt #10's clinical record was reviewed on 12/ 26/12 at approximately 11:00 AM. Pt was a 59 year old male admitted with Acute Respiratory Failure, Status Post Tracheostomy, Anoxic Brain and Hypertension. Pt #10's clinical record contained wound care orders dated 11/15/12 to apply Maxorb dressing with Exuderm daily and as needed to sacrum; apply thin layer of Vasolex every shift and as needed to forehead. The clinical record documentation dated and timed 11/15/12 at 4:22 PM included, "wound present to forehead". The clinical record lacked documentation that wound care to the forehead was followed.

5. The Director of Patient Care Services (E #7) was interviewed on 12/27/12 at approximately 10:00 AM. During the interview, E#7 stated that the Hospital's practice is for a nurse to perform wound care and skin care following the Hospital's Wound Care Nurse's specific orders. E#7 stated that the Hospital staff did not follow wound orders for Pt #4, Pt # 5 and Pt #10.


B. Based on review of Hospital documents and interview, it was determined that in 3 of 10 (Pt #4, Pt #7 & Pt #9) clinical records reviewed of patients with central venous catheters, the Hospital failed to ensure the Registered Nurse (RN) changed central venous catheter dressings.

Findings include:

1. Hospital policy entitled, "Cental Venous Catheters" , (revised 4/11 ) , required, "Purpose A. 2. PICC lines (peripherally inserted central catheters ) 3. Triple Lumen Catheters (TLC) and Policy : C. The Registered Nurse is responsible for the care and maintenance of central venous access catheters. D. Central venous catheter dressings are routinely changed on admission, then every Tuesday, and as needed if the dressing becomes wet, soiled or loose.

2. The clinical record of Pt #4 was reviewed on 12/26/12 at approximately 11:00 AM. Pt #4 was a 58 year old female admitted on 11/30/12 with diagnoses of Osteomyelitis and Cellulitis in Sacrum secondary to sacral decubitus stage IV, Schizophrenia and Schizoaffective Disorder and Panic Attacks, Hyperlipidemia, and Anemia. Pt #4's clinical record included documentation dated and timed 12/1/12 at 3:52 AM that the patient had a PICC line on the right upper arm. The clinical record lacked documentation that the PICC line dressing was changed on Tuesday,12/4/12.

3. The clinical record of Pt #7 was reviewed on 12/26/12 at approximately 11:00 AM. Pt #7 was an 87 year old male admitted on 11/13/12 with diagnoses of Abdominal Wall Wound Status Post Exploratory Laparotomy, Methicillin Resistant Staphylococcus Aureus Infection of the Wound and Insulin Dependent Diabetes. Pt #7's clinical record contained documentation dated 11/28/12 at 10:51 AM that the patient had a right upper arm PICC line. The clinical record lacked documentation that the PICC line dressing was changed on Tuesday, 12/4/12.

4. The clinical record of Pt #9 was reviewed on 12/26/12 at approximately 11:00 AM. Pt #9 was a 64 year old female admitted on 12/8/12 with Status Post Abdominal Wall, Labia and Perineal Cellulitis and Acute Renal Failure. Pt #9's clinical record contained documentation dated and timed 12/11/12 at 7:13AM that patient had a right upper arm PICC line. The clinical record lacked documentation that the PICC line dressing was changed on Tuesday, 12/18/12.

5. The Director of Patient Care Services (E #7) was interviewed on 12/27/12 at approximately 10:00 AM. During the interview, E # 7 stated that the Hospital's practice is for Registered Nurse to change Central Venous Catheter dressings upon admission and every Tuesday. E#7 stated that the Hospital did not perform venous catheter dressing changes for Pt #4, Pt # 9 and Pt #10 on 12/4/12.