HospitalInspections.org

Based on document review and interview, it was determined the facility staff failed to maintain patient care in a safe setting by not following facility policies and procedures and not following the physician plan of care as ordered for one (1) out of four (4) patients.

The findings include:

A review of the medical record for Patient # 2 by the surveyor on 11/07/19 at 3:40 p.m. revealed that Staff Member #8 ordered daily continuous wound care of "Sacrum: Thera honey moist gauze and cover daily" on July 17, 2019. Additionally, Staff Member #8 ordered turning and repositioning of Patient #1 every two hours continuously on the same date. A further review of the medical record by the surveyor did not reveal evidence of the daily wound care treatment being performed as ordered on August 1, 2019. Nor did the review of the medical record uncover documentation of turning or re-positioning of the patient throughout the day of June 12, 2019

On 11/08/19 at 1:50 p.m. during a surveyor interview with Staff Member #3, Staff Member #3 advised that after consulting with Staff Member #2, documentation of performing wound care and turning and repositioning of Patient #1 was not available.

A review of facility policy titled, "Guidelines for Nursing and Respiratory Care (with last revision date of September 2019) reads that nurses are to review and sign the patient ' s medical record for physician orders "ongoing and per physician rounding, minimum every twelve (12) hours." Additionally, under "Activity and Mobility" section, "Bedfast patient to be turned and documented every two hours and as per physician ordered."