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Based on record review and interview, the hospital failed to ensure a registered nurse evaluated and provided the ordered nursing care of 3 of 10 patients (Patient #1, #6, and #10) reviewed, in that, Patient #1's, #6's, and #10's wound care orders were not documented completed as ordered for their respective admissions.

Findings Included

Patient #1's electronic record did not reflect the "Pin Site Care" was completed daily on 01/25/2015, 01/26/2015, 01/29/2015, 01/30/2015, 02/10/2015, 02/12/2015, 02/17/2015, and 02/19/2015 as ordered.

Patient #1's electronic record reflected the Pin Site Care was, "Not done, cancel this execution, performed by other discipline" on 01/26/2015, 01/29/2015, 01/30/2015, 02/10/2015, 02/12/2015, and 02/17/2015. There was no charting to reflect the pin site care was completed by another discipline.

Patient #6's electronic record did not reflect the wound care was completed on 05/22/2015 and 05/25/2015 as ordered.

Patient #10's electronic record did not reflect the wound care to the right great toe was completed on 05/02/2015 as ordered.


During the electronic medical records review on 05/28/2015 starting at 11:10 AM and ending at 4:09 PM, Personnel #4 navigated the records and confirmed the findings of Patient #1's, #6's, and #10's wound care was not documented completed as ordered for the respective patients and dates.