HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on medical record reviews, review of facility policy and interviews with the facility staff, it was determined the medical record (MR) did not include orders, measurements or treatment documentation necessary to monitor the patient's condition in 6 of 8 patients with wounds. This affected MR #'s 4, 5, 8, 11, 12 and 13.

Findings include:

The policy titled "Wound and Skin Care" included, "A. Assessment and Documentation......Assess all areas of skin breakdown/wounds on admission and weekly, and document the following.......d. Size: Measure the wound (area and depth) weekly and record in centimeters. B. Wound Treatment. 1. If specific wound care orders have been written in the medical record, follow the orders, not the protocols.........Skin protocols can be implemented as indicated by the licensed nurse. The licensed nurse must write a verbal order indicating which protocol has been implemented including prevention protocol."

1. MR # 4 was admitted on 1/24/11 with diagnosis of Multiple Sclerosis. A review of the admission nursing assessment, dated 1/24/11, revealed a superficial Stage II pressure sore on the right buttock. There were no measurements and no physician orders for treatment to this area.

A review of the nurse daily progress notes from 1/24/11 to 2/03/11 revealed no documentation of treatment to this pressure area.

An interview on 3/16/11 at 10:40 AM with Employee Identifier # 1, Chief Nursing Officer, confirmed the pressure area orders, measurements and treatment care were not documented.



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2. MR # 5 was admitted on 2/24/11 with diagnosis of Cerebrovascular Accident (CVA).
A review of the MR revealed that the patient had developed a wound to the left great toe on 3/7/11.
A review of the Skilled Nurse (SN) "Wound Addendum/Status Update and the Wound Treatment Form" from 3/7/11 to 3/13/11 revealed the SN provided daily wound care as follows: cleansed with wound cleanser, covered with gauze and secured with tape. There was no physicians order for wound care documented in the patient's record.

A review of the MR revealed there were no wound measurements documented by the SN on the initial wound assessment on 3/7/11 to 3/14/11.

An interview conducted on 3/17/11 at 9:05 AM with EI #1 confirmed the above.


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3. MR # 8 was admitted on 11/03/10 with diagnosis of Status Post Right Above The Knee Amputation and a Stage II Pressure Ulcer to the Right Buttock. A review of the admission nursing assessment, dated 11/03/11, revealed a Stage II pressure ulcer on the right buttock and a post surgical wound to the right stump with staples. There were no measurements documented by the SN 11/03/10 to 11/18/11 as specified per agency wound policy.

An interview on 3/16/11 at 10:40 AM with Employee Identifier # 1, Chief Nursing Officer, confirmed there were no measurements of the wounds documented by the SN and the wound care policy was not followed.

4. MR # 11 was admitted on 1/19/11 with diagnosis of Spinal Cord Injury Traumatic/T10-12 Paraplegia. A review of the admission nursing assessment, dated 1/19/11, revealed a Stage II pressure sore on the coccyx and a post surgical wound between scapulas. A review of the MR revealed there were no wound measurements documented by the SN on the initial wound assessment 1/19/11 to 2/08/11 as specified per agency wound policy.

An interview on 3/16/11 at 10:40 AM with Employee Identifier # 1, Chief Nursing Officer, confirmed there were no measurements of the wounds documented by the SN and the wound care policy was not followed.



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5. MR # 12 was admitted on 2/1/2011 with diagnosis of C5-6 Cord Contusion. A review of the admission nursing assessment, dated 2/1/2011, revealed a pressure sore on the coccyx area. There were no measurements and no physician orders for treatment to this area.

A review of the nurse daily progress notes dated 2/2/2011 and 2/7/2011 revealed the nurse applied Allevyn to the area. There was no physician's order for the Allevyn.

6. MR # 13 was admitted on 3/1/2011 with diagnosis of Multiple Sclerosis. A review of the admission nursing assessment, dated 3/1/2011, revealed a superficial Stage I pressure sore on the coccyx area. There were no measurements and no physician orders for treatment to this area.

A review of the nurse daily progress notes from 3/1/2011 through 3/14/2011 revealed no documentation of treatment to this pressure area.