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MARION COMMUNTIY HOSPITAL 1431 SW 1ST AVE OCALA, FL 34478 May 3, 2017
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview, record review, and policy and procedure review, the hospital failed to ensure nursing care and services were provided as needed for wound care instructions at the time of discharge for 2 of 5 sampled patients, Patients #1 and #7.

Findings:

1.) During an interview on 5/2/2017 at 3:06 PM via telephone with the Patient #1's spouse she stated, "I didn't notice the blister during the admission it was some time that week. He got the blister while he was there. I'm not sure of the day that it developed. I did report it to the nurse and she came in and looked at it. I noticed the wound on the 21st or the 22nd. I will have to look at my calendar; it was the 22nd. I called his primary care giver, and they told me it would be a couple of days before he could be seen. I told them he was a diabetic and that he had an open wound. They were able to get him in the afternoon that I called. The doctor ordered home health, and the home health nurse came out and did wound care. It was a stage II pressure ulcer. There was no information on the discharge paperwork about the pressure ulcer; no wound care or home health to take care of it."

Record review of Nursing Reassessment showed, dated 3/17/2017, Stage II to right buttocks. Use foam wedge for <30 degree lateral positioning. Dated: 3/20/2017 at 7:30 AM Mepilex to right buttock pressure ulcer Stage II. There was no additional documentation by the nursing staff related to the pressure ulcer.
Record review of the discharge instructions showed, dated 3/20/2017 at 3:02 PM, there were no instructions or documentation of a pressure ulcer to the buttock.

Record review of the Skin Risk Interventions showed, dated 3/17/2017 and 3/20/2017 - Manage moisture, avoid drying the skin, manage nutrition, maintain good hydration, manage friction and shear, no massage of reddened bony prominences, reposition every 2 hours as needed, offer toileting when turning, pericare as needed, use moisture barrier; body wash and lotion routinely, maximal remobilization-up chair for meals when appropriate, protect (offload) heels, use turn sheets to reduce friction/shear, Head of bed , <30 degrees unless medically contraindicated, consider pressure relieving surface (if bed or chair bound), provide education on pressure ulcers to patient and family, assess nutrition status, obtain nutrition consult as needed, use foam wedges for 30 degree lateral positioning, consider trapeze if indicated, monitor all body folds for moisture, yeast, rash, irritation.

During an interview on 5/3/2017 at 3:07 PM with the Director of Quality (DOQ) she stated, "There is a point where I will argue and there is a point where I wouldn't even try, I looked at everything and there is nothing there that I can find. I don't see any documentation from the physician. There are no discharge instructions regarding the wound."

During an interview on 5/3/2017 at 6:50 PM with the Director of Nursing (DON) she stated, "When a patient is discharged who has a pressure ulcer the discharge instructions will document whatever wound care is needed under the discharge instructions. When discharged home, to an institution or facility, the discharge transfer, instructions and notes will be provided."

2.) Record review of the Nursing Reassessment for Patient #7, dated 3/30/2017, showed left buttock pressure ulcer Stage II. Dated: 4/1/2017 Left buttock pressure ulcer Stage II. Opticel ZGuard, dry with old drainage. Dated: 4/2/2017 showed there was no documentation of the pressure ulcer.

Record review of the discharge instructions showed, dated 4/2/2017 at 12:53 PM there were no instructions provided for wound care or documentation of the wound.

Record review of the Skin risk interventions showed, dated 3/30/2017 and 4/1/2017, Manage moisture, avoid drying the skin, manage nutrition, maintain good hydration, manage friction and shear, no massage of reddened bony prominences, reposition every 2 hours as needed, offer toileting when turning, pericare as needed, use moisture barrier; body wash and lotion routinely, maximal remobilization-up chair for meals when appropriate, protect (offload) heels, use turn sheets to reduce friction/shear, Head of bed , <30 degrees unless medically contraindicated, consider pressure relieving surface (if bed or chair bound), provide education on pressure ulcers to patient and family, assess nutrition status, obtain nutrition consult as needed, use foam wedges for 30 degree lateral positioning, consider trapeze if indicated, monitor all body folds for moisture, yeast, rash, irritation. Supplement regular turns with small position shifts. Consult specialty support bed algorithm for support surface. Monitor bony prominences, wounds; use pillow for offloading.

Record review of Additional Interventions: showed dated 3/30/2017, Must check him all the time/he will not call to be changed due to the pain of wiping him. Must turn him even if he says no. His back side is getting worse.

During an interview on 5/3/2017 at 4:26 PM with the DOQ, she stated there is no documentation on the date of discharge about the wound, and there is no documentation on the discharge instructions related to the wound, and the care that needed to be provided. They discussed it with his sister, maybe they told her he needed the wound care. When asked if instructions are to be documented on the discharge instruction sheets, the DOQ stated, "Yes." When asked if the Stage II pressure ulcer could have healed in one day, the DOQ stated, "No."

Record review of the Policy and Procedures titled, "Discharge Process" Effective: 2/1/1995 and Approved: 12/28/2016, showed Procedure 3. Patients and parents or guardian of neonates, children, adolescents and adults discharged from the hospital, will receive instructions and individualized teaching prior to discharge. Such instructions and/or teaching as well as patient and/or family verbalization or demonstration of understanding will be documented in the medical record. All discharge instructions will be consistent with the responsible physicians' instructions, and will be age appropriate.