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AVENTURA HOSPITAL AND MEDICAL CENTER 20900 BISCAYNE BLVD AVENTURA, FL 33180 Sept. 19, 2012
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure that the nursing staff keep the wound care assessments and documentation current for 3 of 10 sample patients( SP#1, SP#3, SP#4) needing wound care services .


Findings include:


1). Clinical record review of SP#1 conducted from 09-17-2012 to 09-19-2012 revealed that SP#1 came to the hospital complaining of shortness of breathing and was admitted on [DATE]. April 14, 2012, SP#1 had removal of the AICD and leads and the surgery was performed by Surgeon (Surg.) #1 due to an infected AICD. SP#1 went to the Post-Anesthesia Care Unit (PACU) and later was transferred to the Intensive Care Unit (ICU).

Review of the clinical record conducted from September 17-19, 2012 failed to show any written post-operative (post-op) orders from the surgeon on April 14, 2012.

The Director of Risk Management (Dir. of RM) stated during an interview conducted on September 18, 2012 from 10:15 A.M. to 10:25 A.M. "There were no orders written post-op. The Computerized Provider Order Entry (CPOE) was checked for any orders just to be sure but there were no orders".

The Director of Stepdown/Telemetry unit (Dir. of Stepdown/Telemetry) stated during an interview conducted on September 17, 2012 from 11:47 a.m. to 12:45 P.M. "The staff failed to call the doctor regarding getting an order for the dressing change. The patient stayed on this floor for four (4) weeks. The wound assessment was not done".

The Dir. of RM stated during an interview conducted on September 18, 2012 from 10:15 A.M. to 10:25 A.M. "I reviewed the nurses' notes and found that the dressing change was done on certain dates only. Some nurses did not describe the incision, others had no documentation at all".

The Dir. of Step down/Telemetry unit stated during an interview on September 19, 2012 from 8:50 A.M. to 9:10 A.M. "The original dressing was removed by the surgeon. There was another dressing placed. When I asked the nurses who took care of the patient, there were reinforcements of the post-op dressing done but no fresh dressings applied".

The above findings were confirmed from the Assistant Chief Nursing Officer, the Vice-President of Quality Management, the Dir. of Step down/ Telemetry unit and the Dir. of RM on September 19, 2012 at 3:20 P.M. that there was failure to ensure that the care and treatment decisions are based on the needs of a post-operative patient.

(2). Clinical record review of SP#3 conducted from 09-17-2012 to 09-19-2012 revealed that SP#3 was admitted on [DATE] . Review of the Adult Admission Assessment form showed that SP#3's skin was intact on admission. On 06-27-2012, while the patient was in the Intensive Care Unit (ICU), it was documented that SP#3 had a Stage II pressure ulcer noted on the sacrum.

The Wound Care Specialist documentation on July 5, 2012 showed that Santyl ointment was recommended for the sacral ulcer. The WC RN #1 stated during an interview conducted on September 19, 2012 from 11:10 to 11:39 A.M. " The presence of fibrin means dead tissue and the Santyl ointment acts as an instant debrider to eat up the dead tissue.

Further review of the pressure ulcer documentation as to what type of wound care were provided for the Stage II sacral pressure ulcer during daily wound care were incomplete as to what medication was applied to the pressure ulcer, and descriptions about the pressure ulcer to indicate whether the pressure ulcer showed improving or not on a consistent basis. .

The Dir. of WC stated during an interview conducted on September 19, 2012 from 11:10 A.M. to 11:39 A.M. " It is possible for a patient who has been turned and repositioned to still develop pressure sores, especially when there is a compromise in nutrition and the presence of other co-morbidities " .

(3) SP#4 was admitted on [DATE]. Review of the Adult Admission Assessment form showed that SP#4's skin was intact on admission. SP#4 was last seen by the Wound Specialist on 02-08-2012 and it was documented that the patient has a Stage II pressure ulcer on the left buttock with a small satellite wound in the gluteal cleft with measurements taken at both sites. The recommendation is to continue applying the Santyl ointment. Review of the Patient Care Notes revealed that dressing changes were done but failed to show what medication was applied to the pressure ulcer, there and descriptions about the pressure ulcer to indicate whether the pressure ulcer was improving or not and no measurements were documented on a consistent basis. Further record review revealed that 03/29/12 the pressure ulcer had progress to a stage 3 pressure .

The Dir. of Stepdown/Telemetry unit stated during an interview conducted on September 17, 2012 from 11:47 A.M. to 12:45 P.M. " The Certified Nursing Assistants ' (CNA) reporting are done between CNA to CNA, they also receive report from the nurses. They utilize a worksheet to document information about the patients. I collect these worksheets and I do random checks on documentation like the rounding, turning schedules. I check on the documentation of the nurses, too. If there are any inconsistencies, I address it with the staff. Patients at high risk for skin breakdown are identified on assessments by the nurses, patients who score less than eighteen (18) on the Braden scale will trigger a need to be seen for nutritional support or Wound Care consult, an air mattress may be recommended as part of the treatment. There is a Suggested Reposition Schedule chart posted inside the patient ' s room as a reminder for the staff. The skin care regimen includes use of a spray, a cream/barrier and another thicker cream " .




Review of the Skin Integrity Risk Assessment/ Pressure Ulcer Wound Prevention policy reveled that 5.1-2 states that the assessment of the skin conditions will be documented in the medical record at least every 12 hours. The presence of pressure ulcers will include location, stage, wound dimensions , characteristics, and the wound care interventions/dressing changes.