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.
|WELLSTONE REGIONAL HOSPITAL||2700 VISSING PARK RD JEFFERSONVILLE, IN||Sept. 27, 2018|
|VIOLATION: MEDICAL STAFF BYLAWS||Tag No: A0353|
|Based on document review and interview, the facility failed to ensure medical record (MR) documentation included orders for treatment of wounds in 1 (MR 1) of 10 MR's reviewed:
1. Review of Medical Staff Rules and Regulations, indicated on page 7: "5.4.1 All orders for medications and/or treatment for patients admitted to the Facility shall be in writing".
2. Review of patient 1's MR lacked documentation of physician orders for treatment of the patient's left big toe and right foot wounds and bruising to bilateral hands/feet.
3. On 9/27/18 at approximately 1300 hours, staff N1 (Director of Nursing) was interviewed and confirmed patient 1's MR lacked documentation of physician orders for wound treatment.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on document review and interview, the facility failed to ensure the medical record (MR) included documentation of daily assessments and treatment of wounds and fall risk assessments in 1 (MR 1) of 10 MR's reviewed:
1. Policy/procedure, Skin Assessment, revised/reviewed 8/16, indicated on page 2: "A nurse should document carefully the condition of any wounds the patient may have. Appearance of the wound should include information about whether it appears infected, size of wound or skin tear, warm to touch, location, edematous, sutures intact, etc. If the patient has a decubitus, it should be given an approximate stage level. The colors appearing in bruises also should be documented as this is an indication of age in bruising if any allegations of abuse or injury are made".
2. Policy/procedure, Wound Irrigation, revised/reviewed 8/16, indicated: "Wound care and irrigation shall be performed by a licensed nurse as ordered by the physician to clean the wound and prevent infection. Document procedure, including patient teaching and patient response in the medical record".
3. Policy/procedure, Fall Risk, revised/reviewed 2/18 indicated on page 3: "Reassess the patient daily to determine if the risk of falls has changed".
4. Review of patient 1's MR lacked documentation of skin assessments and treatment of the patient's left big toe and right foot wounds and lacked documentation of assessments of bruising to bilateral hands/feet. Review of patient 1's MR also lacked documentation of daily assessment of patient's risk for falls and implementation of fall risk interventions.
5. On 9/27/18 at approximately 1300 hours, staff N1 (Director of Nursing) was interviewed and confirmed patient 1's MR lacked documentation per nursing staff of wound assessments and lacked documentation of daily falls risk assessment and implementation of precautions.