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.
|COOKEVILLE REGIONAL MEDICAL CENTER||1 MEDICAL CENTER BOULEVARD COOKEVILLE, TN 38501||Aug. 6, 2018|
|VIOLATION: PATIENT CARE ASSIGMENTS||Tag No: A0397|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, medical record review, and interviews, the facility failed to provide an ordered consultation timely for one patient (#2) of 6 patients reviewed.
The findings included:
Review of facility policy "Skin and Wound Care" last revised 3/2017, revealed "...A standard protocol involving interdisciplinary approach to skin care and prevention and treatment of wounds and pressure ulcers (injury) shall be adopted..."
Medical record review revealed Patient #2 was admitted to the facility on [DATE] for diagnosis including Dyspnea (shortness of breath), Pneumonia, End Stage Renal Disease, and Congestive Heart Failure.
Review of a physician's order dated 5/19/18 at 2:36 PM revealed "...CONSULTATION...wound care..." Further review revealed no documentation the wound care consultation was provided until 5/28/18 (9 days later).
Medical record review of a wound care progress note dated 5/28/18 at 6:20 PM revealed "...Buttocks/sacrum total area 11 cm [centimeters] X 10 cm several areas of partial thickness skin loss...this is related to moisture but pressure cannot be excluded..."
Interview with the Wound Care Nurse on 8/2/18 at 12:20 PM, in the Quality Assurance Conference Room, confirmed there was a physician's order for the wound care consultation for Patient #2 on 5/19/18 and the consultation was not provided until 5/28/18.
Interview with the Vice President of Quality and the Risk Manager on 8/2/18 at 2:20 PM, in the Quality Assurance Conference Room, confirmed there was no documentation the wound care consultation was provided prior to 5/28/18. Further interview confirmed wound care nurses were on-call and available on 5/19/18. Continued interview revealed the patient was not provided a wound care consult timely as ordered by the physician.