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MANATEE MEMORIAL HOSPITAL 206 2ND ST E BRADENTON, FL 34208 Jan. 14, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care related to wound care needs for two (#1, #2) of twelve sampled patients. This practice does note ensure patient goals are met and may result in prolonged hospitalization .

Findings include:

Patient #1's History and Physical dated 9/23/12 at 12:07 a.m. and signed by the attending physician noted there was an infected looking blister on the sole of the right foot that was draining.

Review of the Electronic Medical Record orders page revealed an order to consult the Wound Care Nurse was generated by the computer software on 9/22/12 at 11:50 p.m. A second order to consult the Wound Care Nurse was signed by the attending physician on 9/23/12 at 1:42 p.m.

On 9/26/12 at 8:42 a.m., the fourth day of the patient's hospitalization , the attending physician signed a third order to consult the Wound Care Nurse today to address the foot ulcer.

The wound care assessments note revealed an entry by the Wound Care Nurse dated 9/25/12 at 10:47 a.m. The note indicated the patient was receiving intravenous antibiotic therapy for a left lower leg cellulitis. Further review of the record failed to reveal any documentation of the appearance, size or location of the infected looking blister on the sole of the patient's foot as mentioned in the History and Physical. Detailed review of the record failed to reveal documentation by any nurse of any treatment to the foot between the admission on 9/22/12 at 9:34 p.m. and 9/26/12 at 10:30 a.m.

The wound care assessments note dated 9/26/12 at 10:30 a.m. and signed by the Wound Care Nurse (WCN) documented a blister on the bottom of the patient's foot. The note further described a Stage II 2 centimeter (cm) pressure ulcer on the patient's coccyx/sacral area and the application of a duoderm dressing and skin sealant to the pressure ulcer.

A review of the Flowsheet Power Note revealed the first documentation of assessment of the foot blister and pressure ulcer appeared on 9/24/12 at 2:00 p.m. There is no documentation of any nursing care or treatment of either wound until the note by the WCN on 9/26/12.

Review of the policy and procedure "Skin Care, Prevention, and Management of Wounds" Policy #S 02.0, review date 4/2013 Section III Procedures: C. 1 indicated if a patient is admitted with or develops skin breakdown, a photograph should be taken and placed in the Progress Notes. C.2. indicated a disposable measuring device should be used to measure the length and width of the wound. C. 3. Indicated the staff nurse should consult the Wound Care Nurse and the physician.

A detailed review of the record failed to reveal any photographs were taken of Patient #1's wounds at any time during his hospitalization . There were no measurements of either of the wounds documented during the patient's hospitalization with the exception of the one Wound Care Assessment note by the Wound Care Nurse on 9/26/12. The record failed to reveal any documentation why the delay by the Wound Care Nurse or that the physician had been notified.

An interview was conducted with the Nurse Manager of the 4 North Tower medical/surgical nursing unit on 1/14/13 at approximately 12:45 p.m. In response to questions regarding the services of the Wound Care Nurse, she indicated the nurse makes rounds depending on patient needs ranging from daily to once a week. She stated she would expect the Wound Care Nurse to respond to a physician's order for consultation within 24 hours. If the Wound Care Nurse was not available, she would inform the physician. She stated each nursing unit has a wound care super-user who has been trained by the Wound Care Nurse, and if the Wound Care Nurse was not available the super-user would see the patient.

An interview was conducted with the Wound Care Nurse on 1/14/13 at approximately 2:40 p.m. She indicated she makes rounds on every nursing unit every day Monday through Friday. There is a nurse who covers for her when she is scheduled off.

An interview was conducted with the RN staff nurse on the 5 Radial North nursing unit on 1/14/13 at approximately 2:50 p.m. In response to questions regarding the facility policy for wound care, she stated upon discovery of a patient with a wound, she would call the physician for orders for wound care and consultation with the Wound Care Nurse and fake a picture of the wound.

An interview and record review was conducted with the Quality Manager and the Director of Risk Management on 1/14/13 at approximately 4:00 p.m. No explanation was revealed regarding the delay in obtaining a consultation with the Wound Care Nurse. They confirmed the findings that Patient #1 did not receive wound care in accordance with established facility policies and procedures.

2. Patient #2's History and Physical dated 1/7/13 at 9:50 p.m. indicated the patient was admitted on [DATE] for treatment of an infected surgical scar from a previous surgery.

The assessments note dated 1/7/13 at midnight noted the patient had a 6 cm x 2 cm pressure ulcer on her right hip. A detailed review of the assessments revealed no documentation of the assessment, nursing intervention or reassessment of the right hip pressure ulcer between 1/9/13 at 10:00 p.m. and 1/12/13 at 12:59 a.m., a period of more than 48 hours.

A review of the "Plan for Patient Assessment and Reassessment" Policy #PC509 Effective date 04/2012 Section VII. Assessment/Reassessment A. General Medical/Surgical inpatient units indicated reassessment occurs every shift or more frequently as indicated by the patient's condition.

An interview and record review was conducted with the Nurse Manager on 1/14/13 at approximately 1:30 p.m. She confirmed the findings that no documentation of the assessment, nursing intervention, or reassessment of the patient's right hip pressure ulcer was present in the record for a two day period on 1/10/13 and 1/11/13.