HospitalInspections.org

Based on document review and interview, the facility failed to ensure physician orders were followed for wound care for 1 of 5 patients (patient #4).

Findings include:

1. Review of patient #4's medical record indicated the following:
(A) An order was written on 5/14/14 at 1440 hours for Mist therapy to sacrum for 7 minutes x 5 days. The medical record lacked evidence that the order was carried out for the 5 days. The therapy was completed on 5/14/14, 5/15/14, and 5/16/14 only.
(B) An order was written on 6/2/14 at 1550 hours for Granulex spray to heel bid (twice daily) for 14 days. The medical record lacked evidence that the spray was used twice on 6/3/14 and 6/14/14. The spray was documented as used once on those days.
(C) An order was written on 6/12/14 at 0850 hours to start bid treatment of 1/2 strength Dakins soaked gauze to sacral wound, cover with 2 abd pads and tape. The medical record lacked evidence that the treatment was completed twice on 6/14/14. Per the record, it was only completed once.

2. Staff member #3 (Director of Risk Management and Quality and identified as person to assist with medical records) verified the above at 5:00 p.m. on 9/29/14.