HospitalInspections.org

Based on interview and record review the nursing staff failed to follow physicians orders for 2 of 5 patients reviewed. (Patient ID#'s 1 and 4)

Findings include:

Medical record review of patient ID# 1 dated 5/13/10 to 6/17/10 revealed the following:

-A physician order dated 5/18/10 at 10:45 a.m. stated "Potassium Chloride 40 meq via peg tube times-one now." The medication administration record dated 5/18/10 reflected the Potassium Chloride was not administered until 1:00 p.m. ( 2 hours and 15 minutes after the order was written).

Record review of a policy and procedure titled "Medications: Standard Administration Times" dated 8/11/03 stated "Now" orders should be administered "within one hour from the time the order was received."

-A physician order dated 6/9/10 at 2 a.m. stated "Give Normal Saline 250 cc intravenous now." The medication administration record dated 6/9/10 revealed no documentation the Normal Saline was administered as ordered.

-A physician order dated 6/14/10 at 7:15 p.m. stated "Vancomycin one gram intravenous every 12 hours." The medication administration dated 6/15/10 revealed the first dose of Vancomycin was not given until 9 a.m. (13 hours and 45 minutes after the order was written).

Interview 12/28/10 at 1 p.m. with a Pharmacist (ID# 54) revealed the Vancomycin for patient ID# 1 should have been administered at 9 p.m. on 6/14/10 and not the next day.

-A physician order dated 5/17/10 at 1 p.m. stated "Wound consult to evaluate left thoracic incision and incision sites. Nursing assessment on admission 5/13/10 noted "Sternal Incision." A wound consult on 5/18/10 failed to evaluate the sternal incision. A picture taken of the sternal incision on 5/30/10 revealed the lower portion of the sternal incision was reddened with a yellow area. Physician progress notes on 6/14/10 stated "Sternum with abscess, start antibiotics."

-A physician order stated 5/29/10 stated "wet to dry dressing to sternal wound twice daily. Nursing notes reflected on 5/29/10 the initial wet to dry dressing was documented. The nursing assessments failed to document the dressing changes twice daily. The sternal incision developed an abscess and was lanced on 6/14/10 according to the physician progress notes.

Wound care notes revealed pictures of the sternal wound were taken 5/30/10, and 6/15/10. The pictures on 5/30/10 and 6/15/10 showed redness and a yellow area. No measurements were taken of the sternal incision wound on 5/30/10 or 6/15/10. No picture was taken the week of 6/7/10.

Record review of a policy titled "Wound Assessment" dated 6/10/08 stated "Photographs of the wound will be taken weekly....." The policy further stated "The assessment of a wound will include at a minimum location, size, tunneling, undermining, drainage, odor, color and surrounding tissue."


Medical record review of patient ID# 4's revealed:

A wound care note on 11/22/10 stated "stage III pressure ulcer to the Coccyx measuring L x W 2.3 cm x 1 cm."

A physician order on 12/20/10 stated "Wound Care: Please measure size of wound." Record review of wound care notes from 12/20/10 to 12/28/10 revealed the wound was not measured. A picture of the wound was taken on 12/23/10 but no measurements of the wound were documented.

A nurse (ID# 51) acknowledged 12/29/10 at 9 a.m. the physician order dated 12/10/10 for patient ID # 4 was not carried out by nursing staff to measure the wound.