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.
|CLEVELAND CLINIC INDIAN RIVER HOSPITAL||1000 36TH ST VERO BEACH, FL 32960||May 5, 2017|
|VIOLATION: STAFFING AND DELIVERY OF CARE||Tag No: A0392|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review and staff interview, the facility failed to ensure that the nurses consistently performed the prescribed nursing treatments for wound care for 1 of 3 (Patient # 2) patients who was reviewed for pressure ulcers.
The findings included:
The clinical record for Patient #2 disclosed that the patient was admitted to the facility on [DATE] and the initial assessment identified wound issues on her right shoulder. The physician prescribed treatment included, "To cleanse the area with normal saline and apply Mediplex border lite every 2 to 3 days and as needed." Further review of the clinical record failed to provide evidence the nurses performed the prescribed wound care on 03/11/17 and on 03/21/17.
Furthermore, on 03/16/17 the physician prescribed treatment included, "To paint the right humeral wound with Betadine twice daily and cover with a dry dressing." The facility failed to provide evidence that the nurses performed the prescribed twice-daily treatment on 03/19/17 and 03/20/17.
An interview and clinical record review was conducted with the Wound Care Nurse on 05/05/17 at approximately 3:45 PM. She confirmed she was unable to locate documentation that the nurses performed the prescribed treatments.