The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAPTIST HOSPITAL OF MIAMI 8900 N KENDALL DR MIAMI, FL 33176 July 8, 2014
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based upon interview and record review, the facility failed to ensure that care plans were updated with patient's current (skin) problems in 2 out of 10 sampled patients (SP) SP#1 and SP#2.

The findings include:


1. Review of SP#1 closed medical records on 07/07/14 & 07/08/14 showed that the patient was admitted to the facility on [DATE] for fall with injuries to left hip and left knee. Review of Nursing Admission of 04/14/14 at 23:55 pm showed was assessed to be at high risk for skin breakdown and based on this assessment, interventions included turning every 2 hours. The Wound Care Protocol Order on 04/15/14 at 06:30 am showed that the patient had a stage 2 pressure ulcer to the buttocks. Photographic wound documentation on 04/15/14 also show that the patient has a stage 2 decubitus, on the sacrum, that was present upon admission.
Further review of the Photographic Wound Documentation dated 04/15/2014 revealed that there is a stage II sacrum wound x2. Review of the Photographic Wound Documentation dated 04/23/2014 revealed that the sacrum wound had deep tissue injury and had increased in lenth, width. On 05/02/2014 the Photographic Wound Documentation revealed that the wound had increased in size and was unstageable.

Review of the patient ' s Care Plan from 04/14/14 to 05/16/14 did not show that the patient ' s impaired skin integrity was included as one of the problems.

2. Review of SP#2 closed medical records on 07/07/14 & 07/08/14 show that the patient was admitted to the facility on [DATE] for fracture of left femur. Photographic Wound Documentation on 05/02/14 showed that the patient had a scar from a healed ulcer on the sacral area. Review of the Photographic Wound Documentation on 05/14/14 showed that the patient had a stage II pressure ulcer to the sacrum. Nursing Assessments from 05/14/14 to 05/16/14 also showed that the patient had a stage II pressure ulcer to the sacrum.

Review of the patient ' s Care Plan did not show that skin integrity was addressed as one of the patient 's problems.


In an interview with the Director of Nursing Practice on 07/08/14 at 3:30 pm, she stated, " care plans are updated as needed to include all of the patients' concerns.