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Based on observation, record review, and interview, nursing staff failed to:

A. provide ordered wound care to 1 patient (Patient # 10) out of 5 patients (Patient # 8, 9, 10, 11, and 12).

B. provide the initials, date, and time of dressing placement on dressings for 2 patients (Patient #2 and Patient #5) of four patients observed (Patient #1, 2, 3, and 5).

Findings include:

A. Review of Patient #10's chart was conducted on 11-1-2016. Review of the physician orders showed that the physician wrote an order for daily wound care on 8-31-2016. Wound care was documented on 9-1-2016 and was not documented again until 9-5-2016.

Staff #5 was interviewed during the record review. Staff #5 confirmed that the wound care should have been located in the electronic record in the area that all other wound care was being documented. Staff #5 was unable to locate documentation of wound care in other areas of the record.

B. A tour of the unit was conducted on 11-1-2016 with Staff #3. Patient #2 was observed to have a dressing to the right foot. The dressing did not have the nurse initials, date, and time of dressing change on the dressing. Staff #3 verified in the medical record that the dressing change had been completed on 10-31-2016, but the nurse failed to place the initials, date and time of dressing change on the dressing.

Patient #5 was observed to have a peripheral intravenous (IV) catheter (access to a vein for administering medication into the bloodstream) to the right wrist. The dressing was not initialed, dated and timed by the nurse. Staff #3 verified in the medical record that the IV had been placed on 10-31-2016, but the nurse failed to place the initials, date and time of insertion on the dressing.

An interview was conducted with Staff #2 on 11-1-2016. Staff #2 stated that some guidelines and procedures are found on the computer through a company named Elsevier. Others are hospital guidelines. Staff #2 provided the Elsevier guidelines titled "Assessment: Wound" and confirmed this as the guidelines followed by nursing staff for dressing changes. Item #21 stated, "Label the dressing per the organization's practice with the date and time of the application and the nurse's initial."

Staff #2 provided the hospital guideline titled "Intravenous Therapy" with guidelines for initiating an IV. Page 3 of 3, at the top under item 2 states, "Label with nurse's initial, date and time."

Staff #2 confirmed it is the practice of the hospital to require dressings be labeled with the nurse's initial, date, and time the dressing was applied on a wound or over and IV site.

Based on review of records and interview, nursing staff failed to document blood transfusion records per established hospital guidelines on 1 (Patient #6) of 4 patients (Patient # 6, 11, 13, and 15).

Review of Memorial Specialty Hospital Guidelines, Patient Care, Title: Transfusion of blood, was conducted on 11-1-2016. The policy stated on page 3 of 5, item H. Administration, "2. Both nurses must sign, date and time the cross match slip on the lines indicated."

Review of Patient #6 chart was conducted on 11-1-2016. The chart review revealed that on 8-9-2016, the patient received blood products. The cross match slip contained the signature of two nurses. The second nurse did not date and time the signature. On 8-14-2016 the patient received blood products. The first signature line was signed, dated and timed by the nurse. The second signature was missing. Staff #5 verified the findings during record review.

Interview was conducted on 11-1-2016 with Staff #2. Staff #2 confirmed that the policy was current and that two signatures with date and time were required.