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Based on record review and interview, the facility failed to ensure registered nurses obtained orders for wound treatments for 3 of 8 patients reviewed for wound care ( Patients #1, #6 and #11).

-Patient #1 was admitted on 9/26/14 without any documentation of skin issues. On 9/30/14 there were 5 photographs of skin issues. No treatment was ordered for the buttocks and perineal area until 10/3/14. On 10/4/14 the Infectious Disease physician order IV antifungal medication for possible fungal dermatitis of buttock and perineal area.

-Patient #6 was admitted with a stage II pressure ulcer on her left heel. The heel was treated on 12/17/14 with hydrogel without a physician's order. On 12/17/14 an order was given to treat the right heel with collagen every 48 hours. The heel was treated 3 times with collagen and moist gauze. There was no physician's order clarifying the treatment should be on the left heel with use of moist gauze.

-Patient #11 had three skin issues which were being treated by Manuka ointment (Therahoney) and Betadine without a physician's order.

These failures could possibly cause worsening of patient's wounds or cause delay in healing with improper treatments.


Complaint #TX00206558

Findings include:

Patient #1

Record review of Patient #1's closed medical record revealed she was admitted on 9/26/14 at 7:45 p.m. with diagnoses that included electrolyte imbalance and urinary tract infection.

Record review of the patient's admission Physician's Orders dated 9/26/14 revealed no orders for wound treatments.

Record review of Patient #1's History and Physical dated 9/27/14 revealed no skin issues.

Record review of the patient's Pre-Admission Screening Medical Record Review dated 9/26/14 revealed no skin issues.

Record review of the patient's Nurses' Notes dated 9/26/14 through 9/29/14 revealed no skin issues.

Record review of Patient #1's Photographic Wound documentation revealed 5 pictures dated 9/30/14. One was of the left buttock with multiple, small red dots all over the area. A second picture was of the patient's right side of the chin with a raised circular area. The third picture was of a mass on the lower back, the fourth of a red mark on the upper back, and the fifth picture was of multiple raised areas that appeared to be blisters on the fold of the right buttocks. The fifth picture was labeled sacral. There were no descriptions of any of the areas on the documents. On 10/13/14 there was a picture of the patient's buttocks that was labeled sacral. The wound type was deep tissue injury and bruising. The date first observed was hand written 09-26-14.

Further review of the patient's Nurses' Notes from 9/30/14 to 10/3/14 revealed nothing about the patient's physician being called about the skin issues.

Further review of the patient's Physician's Orders revealed an order dated 10/3/14 for Zinc to sacral, buttocks and perineal area daily and as needed.

Record review of the patient's Progress notes revealed on 10/4/14 Physician #60 (an Infectious Disease doctor) noted the patient had a rash and maceration in the perineal area that may be a fungal dermatitis and ordered IV Diflucan.

Record review of the patient's Nurses' Notes dated 10/5/14 at 10:30 a.m. revealed Physician #60 called to clarify the Diflucan order. There was no documentation about the patient's skin condition. At 1:00 p.m. a family member came and was concerned about the patient's health condition. The family member wanted to take the patient home to care for her. At 2:00 p.m. when the family member was trying to get the patient in for a shower, a new skin tear was noted. "Wound nurse & Supervisor on duty took pic (picture) and new treatment with zinc oxide oint. (ointment) to apply to affected area along with frequent reposition q (every) 2 hrs."

Interview on 12/23/14 at 9:55 a.m. with CNO (Chief Nursing Officer) #51, she said she thought the patient had skin issues when she was admitted. She looked through the patient's closed medical record, but did not find any documentation that the patient had been admitted with any skin issues. She said none of the areas that were photographed on 9/30/14 were pressure ulcers. She said the left buttocks was just red. She denied there was a rash. She said the area labeled sacral was on the fold of the right buttock, not over a bony prominence so was not a pressure ulcer. She was asked if she thought the areas were blisters. She did not answer. When she was asked if it was in the area of a Registered Nurse's expertise to diagnose the skin issues, she said the physician would make that assessment and diagnosis. She was not able to show any documentation that a physician had been called when the skin issues were identified and photographed on 9/30/14. She could not say why it took until 10/3/14 (3 days later) to get an order to treat the patient's skin issues; or another 2 days for the Infectious Disease physician to assess the patient's rash and maceration in the perineal area as a possible fungal dermatitis and get IV medication.


Patient #6

Record review of Patient #6's active medical record revealed she was admitted on 12/16/14 with diagnoses that included chronic renal failure and urinary tract infection.

Record review of Patient #6's Physician's Orders dated 12/17/14 revealed an order to start collagen every 48 hours to right heel wound. Further review of the Physician's Orders from admission to 12/17/14 revealed no other treatment orders for the right heel.

Record review of the patient's Wound Care Evaluation dated 12/17/14 at 8:15 a.m. revealed the patient had a stage II pressure ulcer on the back of the left heel that measured 3 cm x 6 cm x 0.1 cm.

Record review of the patient's Wound Treatment & Progress Record dated December 2014 revealed the following:
"12/17/14 - hydrogel with gauze daily (initialed as done on the 17th and a change noted on the 18th)
12/17/14 - puracol plus (collagen) with moist gauze every other day. (initialed as done on 12/17, 12/19, and 12/21/14)
The human diagram figure on the top of the page had a circle around the left posterior heel.

Interview on 12/23/14 at 9:35 a.m. with CNO #51, she said the wound was on the left heel. She said the nurse practitioner wrote the wrong side. She verified that the order did not mention moist gauze. She said she thought collagen had to have moisture to activate it. She was asked if the order should have been clarified. She said it should have been.

Further review of Patient #6's Physician's Orders revealed there was no clarification order written to change the treatment from the right heel to the left heel or to add moist gauze to the treatment. There was no order to apply hydrogel with gauze to the wound.


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Patient #11

Record review of Patient #11's active medical record revealed she was admitted on 12/13/14 with diagnoses that included respiratory failure, chronic renal failure, and bladder infection.

Record review of Patient #11's treatment sheet revealed that Manuka ointment (Therahoney) was applied to the left leg daily and prn (as needed) from 12/20/2014 through 12/22/2014. Betadine paint was use on the right 2nd toe two times a week and prn from 12/20/2014 through 12/22/2014. It was documented on treatment sheet that Manuka ointment (Therahoney) and gauze padding were applied to left wrist daily and prn from 12/20/2014 through 12/22/2014. Further review of the patient's active medical record revealed there was no documentation of a doctor's orders .

During an interview on 12/23/2014 at 9:30 AM, Wound care nurse #55 was asked to look for the doctor's orders for the treatments for Patient #11. Wound care nurse #55 could not find the orders. When asked why the orders were missing she replied that the doctor's assistant probably forgot to write the orders. When asked why were the treatments given without an order, the Wound care nurse #55 had no answer.

During an interview on 12/22/14 at 2:00 p.m. with RN #52, she was asked what the procedure was for a patient identified with a wound. She said the patient would be assessed. The wound nurse would be called to assess the patient also and she would take pictures. The wounds would be documented on a wound care form. If the wound was a pressure ulcer, the wound nurse would measure and stage them. She said the nurse would then get treatment orders from the physician. She said the wounds would be assessed weekly and the treatment would be documented daily. She said the wound nurse would apply zinc oxide the first time each day and the nurse would then apply it as needed with incontinent care. She said if there was a change in the wound, either improvement or decline, the wound nurse would let the nurse know so she could call the physician for a change in the treatment. If the nurse noticed a change, she would let the wound nurse know.

During an interview on 12/23/2014 at 2:00 PM, RN #58 was asked what were the procedures for wound care. RN #58 said that on admission a skin assessment was done, the Wound Care nurses would be alerted about any skin breakdown. The Wound Care Nurse would obtain an order from the doctor for treatment. The primary nurse could also notify the doctor to obtain an order for treatment or for a wound care consult.

Record review of the facility's Policy and Procedure for Wound Dressing Change/Applications dated June 2014 revealed the following:

"Policy:
Wound dressings at (facility) are changed by licensed healthcare professionals in a consistent manner according to physician order and/or if soiled or compromised.

Procedure:
A. GENERAL INFORMATION

Compromise in the integrity of the skin must be treated appropriately to reduce risk of infection or poor healing.

It is the responsibility of each staff member providing care to identify areas of compromise in skin integrity and take appropriate measures to avoid worsening of wound, if possible....

Licensed staff may clean the wound bed with an approved saline base wound cleanser and apply a dressing to keep the wound clean; however, wound ointments/antibacterial, treatments, materials to be applied, frequency, and length of time for wound care require specific physician orders...

Dressings are monitored at least every shift to assess for unexpected outcomes, i.e., redness, swelling, drainage, bleeding...

Wounds are documented in the Medical record stating size, appearance, and presence or absence of drainage."

Based on observation, record review and interview, the facility failed to ensure the hospital environment was maintained for the well-being and safety of patients in 2 of 3 units (Stations 1 and 2).

-Bathroom showers did not have a hose or the hose leaked. There was a open shower drain in room 162.
-There were rusted ceiling tile frames and vents in 3 bathrooms.
-There was a black substance in 3 bathrooms that appeared to be mold.
-There were 18 patient rooms that did not have a way for patients to use over bed lights. There were 2 rooms where the light did not work at the sink and 1 room where the faucet was loose at the sink.
-Toilet paper holders were either sprung, not able to be opened or missing in 7 rooms.
-There were gouges, dents or holes in the sheetrock in 7 rooms.
-There was a build up of lime scale on the ice machine in Station 2 along with a rusted wire rack.
-There was a ceiling light out in the common shower room on Station 1 making the lighting dim in that room.

These failures had the potential for causing safety issues and not enhancing patient well-being for taking showers, for having enough lighting and for infection control issues with rust, gouged sheetrock, mold and toilet paper not in a dispenser.

Complaint #TX00206558

Findings include:

Stations 1 and 2

Observations on 12/22/14 at 9:35 a.m. of Unit 2 revealed the following environmental concerns:

-The following rooms that had bathroom shower stalls had shower hoses that leaked where they tied onto the water pipe or were broken off at the pipe insertion: 162, 107, and 105. The 3 inch shower drain in room 162 needed a cover to prevent patient from getting hurt.

-The following bathrooms had rusted metal ceiling tile frames: 167, 160, and 154. Room 167's bathroom had a rusted vent cover in the ceiling.

- There was a black, linear substance in the edge between the ceiling and the wall in rooms 163 and 103 where there was evidence of a ceiling leak. There were multiple black spots that appeared to be mold below the light fixture and above the mirror in the bathroom in room 105.

-Over bed lights did not have a way for the patient to use them from their beds (such as a pull string) in the following rooms: 100, 101, 102, 104, 105, 106, 154, 156, 157, 158, 159, 160, 161, 162, 163, 165, 167, and 169. In rooms 104 and 163, the light over the sink did not work. The faucet at the sink in room 104 was loose.

-The following rooms had toilet paper holders that were sprung and not able to hold a roll of toilet paper, were not able to be opened to insert toilet paper or missing a toilet paper holder: 163, 167, 169, 162, 160, 104, 154.

-There were gouges and dented, broken sheetrock in the following rooms: 154, 156, 160, 162, 167, 105, and 106. Room 167 had a 24 inch by 2 inch hole in the wall where the head of the bed would be. In room 106 there was an electrical junction box on top of the over bed light for the window bed that was opened. In room 105 there was plaster peeling from around the ceiling vent.

-The ice machine in the nourishment room on station 2 had a build up of lime scale on the black plastic section on the bottom and the wire screen in the bottom holder was rusted.

-In the common shower room on Station 1 a ceiling light was not working. The lighting in the room was dim.

Interview on 12/22/14 at 10:05 a.m. with Director of Plane Operations #54, he said about 5 to 8 shower hoses needed to be replaced. He said the hosed have needed to be replaced for more than 30 days. He said he put in an order to the corporate headquarters at that time, they okayed the order about a week ago and the replacements were due to come in.

Interview on 12/23/14 at 2:20 p.m. with Chief Nursing Officer (CNO) #51, she said the facility had a maintenance work sheet that the staff filled out when there was a maintenance issue. There was a box on Station 1 where the staff could put the sheet in for maintenance to pick up. Interview at this time with Chief Executive Officer (CEO) #50, he said the company had a computer program for any compliance issue or complaint from the employees. It was put in the computer and a prompt would come up asking for a resolution. If there was no resolution then the issue would be sent up the chain of command until it was resolved. He said it was not functional yet at this facility. He said they were still relying on a paper trail for resolution.

Interview on 12/23/14 at 1:45 p.m. with Director of Plant Operations (DPO) #54, he was asked about any room maintenance logs. He said that he made daily rounds and there was a box at the nurses' station that he checked for maintenance requests. He said the shower rooms had had "cosmetic" issues for the past twelve months. He said if he had the supplies, he would do the work. He said he had mainly been concentrating on major compliance items. He said they were all up to date. He said anything cosmetic had fallen to the side. He said the new CEO (Chief Executive Officer) was trying to get things done. He said, for him, his main objectives were safety and compliance.