HospitalInspections.org

Based on interviews and records review, it was determined that the Governing Body was not effective in its oversight of the hospital.

A) The medical staff failed to adequately supervise and ensure adequate medical treatment for one of one patient (Patient #1) whose pre-hospital diagnosed left heel Stage IV ulcer was untreated during her eight day hospital stay from 11/28/12 to 12/05/12.

B) The nursing staff failed to supervise and evaluate the nursing care for one of one patient (Patient #1). Patient #1's left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/5/12. Patient #1 was discharged without a dressing change to her left heel wound.

Findings included:

A) Medical staff noted perfusion complications for Patient #1 but did not evaluate or treat her left heel ulcer. Patient #1 left the hospital after an eight day stay without a wound consult or treatment orders for the wound on her left heel. (Cross refer to A0049)

B) Patient #1 had a pre-hospital diagnosis of a left heel stage IV pressure ulcer covered with a wound dressing dated 11/26/12. Patient #1 was admitted to the hospital on 11/28/12 and discharged on 12/05/12. The dressing to the left heel was not changed during Patient #1's eight day hospital stay. (Cross refer to A0144, A0395 and A0397)

Based on interviews and records review, the Governing Body failed to ensure that medical staff provided quality of care for one of one patient (Patient #1). Patient #1 had a pre-hospital stage IV left heel ulcer. There was no treatment provided to Patient #1's left heel ulcer during her eight day hospital stay from 11/28/12 to 12/05/12.

Findings included:

Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer.

Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be "warm and dry with normal turgor, without lesions or rashes." The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to the hospital.

Physician Admission Orders dated 11/28/12 at 10:15 PM did not include orders for wound care or wound care consultation.

The Admission History and Physical document noted Patient #1 had "pressured, excoriated areas on her sacrum." The assessment reflected "severe peripheral arterial disease of lower extremities" without mention of a left heel wound.

The Consultation Report dated 11/29/12 at 5:45 PM recommended an IVC filter (inferior vena cava filter) "for acute deep vein thrombosis of left lower extremity." The document noted Patient #1 had leg ulcers "with known history of peripheral arterial disease" and would be "treated conservatively."

Physician Order Set Post Cath Orders dated 11/30/12 at 4:20 PM noted patient #1 had a left leg DVT (deep vein thrombosis) and had an IVC filter placed (inferior vena cava filter for recurring thrombosis) without mention of her left heel wound.

The Medication Reconciliation Orders/Discharge Planning Record dated 12/05/12 at 4:01 PM reflected Patient #1 had "blanching to coccyx" (lower back)" without mention of the left heel wound.

Physician Discharge Summary dated 12/05/12 at 3:28 PM reflected Patient #1 had "some swelling over her left lower extremity...which...was positive for deep vein thrombosis" without mention of a left heel wound.

Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 "returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital."

Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was "dated from before she left for the hospital." The physician denied he was consulted for wound management on Patient #1.


Hospital Personnel #10 stated during an interview on 01/16/13 at 10:25 AM she usually did the dressing changes but denied a wound care consult was ordered for Patient #1.


QA/Governing Board Minutes dated 12/21/12 did not reflect skin concerns as PI projects for 2013.

Based on interviews and record review, it was determined that hospital personnel failed to protect and promote the right of one of one patient (Patient #1) to receive care in a safe setting.

Findings included:

Patient #1 was transferred to the hospital on 11/28/12 with a pre-hospital diagnosed left heel pressure ulcer protected by a wound cover dated 11/26/12. The patient was admitted for an eight day hospital stay and was discharged on 12/05/12 without a dressing change to her left heel (cross refer to A0144)

Based on interview and record review, nursing staff failed to provide care in a safe setting for one of one patient (Patients #1) as evidenced by Patient #1's left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/05/12.

Findings included:

Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer.

Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be "warm and dry with normal turgor, without lesions or rashes." The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to a medical bed.

Physician Admission Orders dated 11/28/12 at 10:15 PM did not reflect orders for dressing changes.

The Nursing Admission Assessment dated 11/29/12 at 1:39 AM reflected "skin concerns" on Patient #1's right shoulder and left heel which was further described as "multiple bruises, skin tear to [the] right shoulder [and] right heel injury" which nursing staff was "unable to visualize" due to "drsg (dressing) in place." Nursing skin assessment reflected a right heel wound with dressing.

The electronic "Care Trends - Integumentary" flow sheet dated 11/29/12 at 1:39 AM noted Patient #1 had a wound dressing on her right heel. Flow sheets dated 11/29/12 at 12:54 PM, 11/30/12, and 12/01/12 did not mention wounds or dressings on the patient's feet or heels. Flow sheets dated 12/03/12 at 12:27 PM and 11 PM, 12/04/12 at 1:48 PM, and 12/05/12 at 11:17 AM reflected a "right heel reddened, warm pressure area."

The Medication Reconciliation Orders/Discharge Planning Record dated 12/05/12 at 4:01 PM reflected Patient #1 had "blanching to coccyx" (lower back).

Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 "returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital."

Long-term Nursing Care Facility Staff #3 stated on 01/15/13 at 11:32 AM that he and Physician #12 examined Patient #1 upon returning to the nursing facility after her hospitalization. The patient had a dressing to her left heel which was initialed by the Long-term Care Facility's nursing staff and dated two days prior to Patient #1's hospital admission.

Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was "dated from before she left for the hospital."


Hospital Personnel #10 stated during an interview on 01/16/13 at 10:25 AM she usually did the dressing changes but denied a wound care consult was ordered for Patient #1. Hospital Personnel #10 stated being unaware of any skin issues for Patient #1.

Hospital Employee #11 stated during an interview on 01/16/13 at 11:30 AM she had noticed that computerized documentation stated Patient #1 had a wound to her right foot. Instead, Hospital Employee #11 took the wrapping off Patient #1's left foot. The dressing was "at least a couple of days old" and "dated a few days back" because she "did not recognize the initials on it. It did not look like something PT (Physical Therapy) does." Employee #11 stated she put the same dressing back on Patient #1's left foot and planned to receive further care instructions from another nurse. Employee #11 stated, "I know I needed to follow up on it but I did not do it."

Hospital Personnel #1 was interviewed on 01/16/13 at 12:40 PM. She denied any dressing changes were documented on Patient #1.

Policy RI.120 Patient Rights and Responsibilities approved by the Medical Executive Committee on 10/15/12 reflected the "Right to Care and Services 2.2.7 that...each patient has the right to receive individualized, planned and appropriate care, treatment...based on both an interdisciplinary evaluation of his/her needs and the severity of his/her disease, condition...and on goals, actions and interventions as collaboratively designed and agreed upon by the physicians, nursing staff and other health care providers..."

Based on interviews and record review it was determined the hospital failed to provide nursing service supervised by a registered nurse to one of one patient (Patient #1) whose left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/05/12.

Findings included:

Patient #1 was admitted to the hospital with a left heel pressure ulcer dressed with a wound cover dated 11/26/12. During her eight day hospitalization from 11/28/12 to 12/05/12 Patient #1's wound was documented to be on her right foot. Patient #1 was discharged without a dressing change to her left heel wound (cross refer to A0395 and A0397)

Based on interview and record review, hospital nursing staff failed to supervise and evaluate the nursing care for one of one patient (Patient #1). Patient #1's left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/05/12.

Findings included:

Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer.

Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be "warm and dry with normal turgor, without lesions or rashes." The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to a medical bed.

The Nursing Admission Assessment dated 11/29/12 at 1:39 AM reflected "skin concerns" on Patient #1's right shoulder and left heel which was further described as "multiple bruises, skin tear to [the] right shoulder [and] right heel injury" which nursing staff was "unable to visualize" due to "drsg (dressing) in place." Nursing skin assessment reflected a right heel wound with dressing.

The electronic "Care Trends - Integumentary" flow sheet dated 11/29/12 at 1:39 AM noted Patient #1 had a wound dressing on her right heel. Flow sheets dated 11/29/12 at 12:54 PM, 11/30/12, and 12/01/12 did not mention wounds or dressings on the patient's feet or heels. Flow sheets dated 12/03/12 at 12:27 PM and 11 PM, 12/04/12 at 1:48 PM, and 12/05/12 at 11:17 AM reflected a "right heel reddened, warm pressure area."

Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 "returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital."

Long-term Nursing Care Facility Staff #3 stated on 01/15/13 at 11:32 AM that he and Physician #12 examined Patient #1 upon her return to the nursing facility after her hospitalization. The patient had a dressing to her left heel which was initialed by the long-term facility's nursing staff and dated two days prior to Patient #1's hospital admission.

Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was "dated from before she left for the hospital."

Hospital Personnel #2 stated on 01/16/13 at 11:03 AM that during an educational meeting the day before one of the nurses stated she took the dressing off Patient #1, then reapplied the previously dated and initialed, used dressing back on the wound. Hospital Personnel #2 identified the nurse as a Hospital Personnel #11, a "new LVN (Licensed Vocational Nurse)."

Hospital Employee #11 stated during an interview on 01/16/13 at 11:30 AM she had noticed that computerized documentation stated Patient #1 had a wound to her right foot. Instead, Hospital Employee #11 took the wrapping off Patient #1's left foot. The dressing was "at least a couple of days old" and "dated a few days back" because she "did not recognize the initials on it. It did not look like something PT (Physical Therapy) does." Employee #11 stated she put the same dressing back on Patient #1's left foot and planned to request further care instruction from another nurse. Employee #11 stated, "I know I needed to follow up on it but I did not do it." Employee #11 stated she was recently hired and was just taken off her preceptorship.

Hospital Personnel #1 was interviewed on 01/16/13 at 12:40 PM. She denied any dressing changes were documented on Patient #1.

Policy PC.103 titled Assessment and Reassessment of the Patient dated with Board Approval on 05/17/10 reflected the "Implementation Method 3.1.2.2.1 The Registered Nurse is responsible for the assessment and coordination of patient care."

Based on interview and record review, hospital nursing staff failed to assign nursing care of one of one patient (Patient #1) in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available in that an LVN (Licensed Vocational Nurse) (Hospital Personnel #11) visualized Patient #1's left heel wound, re-applied the used dressing, and did not request further care instructions from an RN. After an eight day hospital stay from 11/28/12 to 12/05/12, Patient #1 was discharged without dressing change of her left heel wound.

Findings included:

Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer.

Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be "warm and dry with normal turgor, without lesions or rashes." The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to a medical bed.

The Nursing Admission Assessment dated 11/29/12 at 1:39 AM reflected "skin concerns" on Patient #1's right shoulder and left heel which was further described as "multiple bruises, skin tear to [the] right shoulder [and] right heel injury" which nursing staff was "unable to visualize" due to "drsg (dressing) in place." Nursing skin assessment reflected a right heel wound with dressing.

The electronic "Care Trends - Integumentary" flow sheet dated 11/29/12 at 1:39 AM noted Patient #1 had a wound dressing on her right heel. Flow sheets dated 11/29/12 at 12:54 PM, 11/30/12, and 12/01/12 did not mention wounds or dressings on the patient's feet or heels. Flow sheets dated 12/03/12 at 12:27 PM and 11 PM, 12/04/12 at 1:48 PM, and 12/05/12 at 11:17 AM reflected a "right heel reddened, warm pressure area."

Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 "returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital."

Long-term Nursing Care Facility Staff #3 stated on 01/15/13 at 11:32 AM that he and Physician #12 examined Patient #1 upon her return to the nursing facility after her hospitalization. The patient had a dressing to her left heel which was initialed by the long-term facility's nursing staff and dated two days prior to Patient #1's hospital admission.

Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was "dated from before she left for the hospital."

Hospital Personnel #2 stated on 01/16/13 at 11:03 AM that during an educational meeting the day before one of the nurses stated she took the dressing off Patient #1, then reapplied the previously dated and initialed, used dressing. Hospital Personnel #2 identified the nurse as Hospital Personnel #11, "a new LVN (Licensed Vocational Nurse)."

Hospital Employee #11 stated during an interview on 01/16/13 at 11:30 AM she had noticed that computerized documentation stated Patient #1 had a wound to her right foot. Instead, Hospital Employee #11 took the wrapping off Patient #1's left foot. The dressing was "at least a couple of days old" and "dated a few days back" because she "did not recognize the initials on it. It did not look like something PT (Physical Therapy) does." Employee #11 stated she put the same dressing back on Patient #1's left foot and planned to request further care instruction from another nurse. Employee #11 stated, "I know I needed to follow up on it but I did not do it." Employee #11 stated she was recently hired and was just taken off her preceptorship.

Hospital Personnel #1 was interviewed on 01/16/13 at 12:40 PM. She denied any dressing changes were documented on Patient #1.

Policy PC.103 titled Assessment and Reassessment of the Patient dated with Board Approval on 05/17/10 reflected the "Implementation Method 3.1.2.2.1 The Registered Nurse is responsible for the assessment and coordination of patient care."