HospitalInspections.org

Based on medical record reviews, review of hospital policies and interviews for one of six patients who had a change in condition and/or skin integrity issues (Patients #1 & #3), the hospital failed to monitor the patients and/or follow standard infection control practices when providing wound care. The finding includes:

1a. Patient #1 had a diagnosis of borderline personality disorder and had an appendectomy on 8/11/11. Physician orders dated 8/12/11 directed daily dry clean dressings to abdominal incisions daily for (7) seven days and as needed for drainage. Although the treatment record and/or observation sheets identified that daily abdominal dressing changes were performed from 8/12/11 through 8/18/11, a seven day period, nursing assessments of the patient's abdominal incisions were not documented. Documentation from a consulting physician dated 8/17/11 identified that the surgeon removed the patient's abdominal staples. Physician progress notes dated 8/22/11 indicated that the patient was seen for ongoing abdominal pain, tan incisional drainage and noted that the midline incision was 3.5 centimeters(cm) with 4 cm of redness and induration below the incision. A nursing assessment of the abdominal incision and/or drainage did not include when the drainage began, nor was documentation available prior to 8/23/11. Although the treatment record noted that the patient's dressing was changed from 8/22/11 to 9/10/11, nursing assessed the abdominal incision on 8/23/11 and additional assessments of the incision were not documented until 9/11/11 when the incision healed. Interview with the Director of Nursing on 2/7/12 at 1:00 PM indicated that nursing could document assessments of surgical incisions on the wound care sheet or in the progress notes. Review of the patient's medical record with the Director of Nursing on 2/8/11 at 1:00 PM noted that a wound care sheet could not be located. The hospital policy for wound care monitoring and documentation identified to document daily on the wound care flow sheets and measure the wound weekly on Wednesdays to include measurements.
1b. Patient #1 had a diagnosis of borderline personality disorder and had an appendectomy on 8/11/11. Consult documentation dated 8/17/11 identified, in part, that the patient had loose stools and to check for Clostridium difficile (c-diff) if ongoing. Nursing documentation dated 8/17/11 noted that the patient had no diarrhea or nausea. Although a stool specimen for C-diff was obtained per physician's ordered on 8/23/11 and was negative, the record lacked assessment of the patient's bowel habits from 8/18/11 to 8/23/11. Physician orders dated 12/6/11 directed Imodium 2 mg after each loose stool for 48 hours, was administered on 12/6/11 at 3:10 PM was ordered and administered again on 12/26/11 and an assessment of the patient's bowel status and/or patient report of bowel status was not documented. In addition, stool cultures were obtained as ordered on 12/27/11 and 12/31/11 and the patient's bowel status was not assessed. Interview with the Director of Nursing on 2/7/12 at 2:10 PM indicated that nursing would monitor bowel status and document loose stools on the treatment record or in the progress notes. Interview with APRN #1 on 2/8/12 at 9:15 AM identified that s/he is made aware of information related to a patient's bowel status through speaking with nursing staff and reading progress notes. Although the hospital did not have a specific policy for bowel monitoring, the progress note policy identified that a nursing staff will document new medical conditions, deterioration in medical status and treatment events, both psychiatric and medical in the progress notes of the patient's medical record until the condition is resolved.
1c. Patient #1 had a diagnosis of borderline personality disorder and had an appendectomy on 8/11/11. Physician progress notes dated 8/22/11 indicated that the patient was seen for ongoing abdominal pain, tan incisional drainage and noted that the midline incision was 3.5cm with 4cm of redness and induration below the incision. Physician orders dated 8/22/11 directed the antibiotics Clindamycin and Bactrim for 7 days. Progress notes dated 8/23/11 identified a moderate amount of serousanguinous drainage from the abdominal incision and that a culture was obtained as ordered. The abdominal wound culture report dated 8/23/11 indicated that the result was reported on 8/26/11 at 10:16 AM and the culture was positive for Staphylococcus species, not aureus. The laboratory report further noted that the organism was resistant to Clindamycin and Sulfa (Bactrim). The patient continued to receive the antibiotics in lieu of the organism's resistance from 8/26/11 to 8/29/11 as originally ordered. APRN #1 and the psychiatrist signed that they viewed the culture report on 8/30/11 and the patient was treated with Doxycycline on 9/1/11 to which the organism was susceptible. Interview with APRN #1 on 2/8/12 at 9:15 AM noted that nursing should have reported the positive culture to him/her or the on-call physician as soon as the result became available. The examination and special tests policy identified that the nurse shall receive results for labs to include all positive cultures (except urine) via fax and notify the Physician/PA/APRN within 30 minutes.
2a. Patient #3 had diagnoses of Diabetes Mellitus, right below the knee amputation and wound to the left inner ankle. Wound clinic documented that the wound measured 2.5cm long by 2.5 cm wide by 0.3 cm deep on 1/10/12. Although the patient's dressing was changed as ordered on 1/17/12 the wound was not assessed again until the scheduled dressing change on 1/25/12 (15 days) and measured 2 cm by 2 cm by 0.3 cm. The wound was assessed by the wound clinic on 1/31/12 and the measurements remained the same as on 1/25/12. Although treatment to the left ankle was administered as ordered on 2/4/12 and treatment change was observed on 2/8/12 the wound was not assessed to include measurements and the next scheduled dressing change was not due until 2/11/12. Review of the wound care sheets and/or nursing narratives with the Director of Nursing and RN #5 on 2/8/12 at 9:00 AM indicated that the patient's wound was not assessed weekly and the wound should have been assessed on 2/8/12 when the dressing was changed. The hospital policy for wound care monitoring and documentation identified to document daily on the wound care flow sheets and measure the wound weekly on Wednesdays to include measurements.
2b. Patient #3 had diagnoses of Diabetes Mellitus, right below the knee amputation and wound to the left inner ankle. Physician orders dated 1/31/12 directed to clean the left inner ankle wound with Normal Saline followed by Medihoney and a 3 layer wrap from the toes to the knee. Observation of the treatment on 2/8/12 at 8:30 AM noted that RN #5 cleansed the center of the ankle wound with Normal Saline, cleansed the outer aspect of the wound and surrounding skin and then dragged the gauze again over the center of the wound. RN #5 discarded the gauze and repeated the cleansing technique. Interview with RN #5 on 2/8/12 at 9:00 AM noted that s/he was not as familiar with providing medical treatments as s/he was with providing care for behavioral problems. Review of the facility dressing change policies did not direct nursing staff to cleanse the wound between dressing changes and/or the cleansing technique to be used to prevent wound infection. According to Lippincott's Nursing Center.com, Wound Wise: Basic wound cleaning step by step, September/October 2008; Moisten gauze pads either by dipping the pads in wound cleaning solution and wringing out excess or by using a spray bottle to apply solution to the gauze. Move from the least contaminated area to the most contaminated area and use a clean gauze pad for each wipe. For an open wound (such as a pressure ulcer), gently wipe in concentric circles, starting directly over the wound and moving outward.