HospitalInspections.org

Based on policy, medical record review and interview, the hospital failed to ensure preventative measures/treatments were implemented/administered as ordered by a physician for 2 of 3 (Patient #1 and 2) sampled patients with wounds.

The findings included:

1. Review of the hospital policy Wound Assessment and Documentation dated 6/1/2021 and reviewed 8/19/2021, revealed "POLICY:...Each patient's wound care will be under the direction of a physician...Responsibilities 1. The physician assumes leadership over clinical interventions and wound care treatment. This may involve the use of protocols previously established by the hospital's medical staff, which may be initiated by the WCC [wound care coordinator], an RN [Registered Nurse] or therapists...The WCC has responsibility for oversight of the wound program. This included review and recommend wound prevention techniques and wound care protocols, training of designated wound stagers, assessment and care of complicated wounds, record reviews for accuracy of documentation, and education of staff...5. Nursing and therapy staff provide wound care as ordered via protocol of physician order..."

2. Medical record review for Patient #1 revealed a hospital admission date of 6/16/2022 with diagnosis of C5 motor incomplete spinal cord injury with central paresis. Patient #1 was discharged on 7/22/2022. A skin assessment dated 6/17/2022 revealed a scar to the right heel, not pressure related from a previous surgery. Physician orders dated 6/20/2022 revealed, Podus boots [multi-purpose foot boot helps prevent and heal ulcers] bilaterally when in bed. Review of the nursing documentation from 6/20/2022 through 7/22/2022 revealed nursing staff documented floating the heels with pillows but did not document the application of Podus boots for 25 of the 31 days reviewed. The nursing staff failed to follow physician orders for application of the Podus boots.

In an interview on 8/29/2022 at 11:30 AM, the Director of Nursing (DON) and WCC verified there was no documentation of the application of Podus boots consistently by nursing.

3. Medical record review for Patient #2 revealed a hospital admission date of 8/16/2022 with diagnosis of generalized weakness, pneumonia and anemia. A skin assessment dated 8/17/2022 revealed an un-stageable deep tissue injury to the buttocks. Physician orders dated 8/17/2022 revealed, clean with wound cleanser and apply optifoam every 48 hours and as needed. Review of nursing documentation revealed the wound was cleaned and the dressing changed on 8/17/2022. There was no documentation of wound care on 8/19/22 or 8/21/2022. The nursing staff failed to provide wound care as ordered by the physician.

In an interview on 8/29/2022 at 11:10 AM, the WCC verified there was no documentation for Patient #2's wound care on 8/19/2022 and 8/21/2022. In an interview on 8/29/2022 at 1:45 PM, the DON verified nursing would perform the wound care and there were none documented for 8/19/2022 and 8/21/2022.