HospitalInspections.org

Based on review of three or five medical record of patients in restraints, it was determined a physician order was not obtained prior to the initiation of restraints. This failed practice had the potential to affect all patients in the facility. The findings follow:

Patient #2 was in a vail bed for 29 days from 12-29-10 till 01-26-11. There was no physician order for the use of restraints on the following days:
01-04-11, 01-08-11, 01-09-11, 01-10-11, 01-15-11, 01-16-11, 01-17-11, 01-18-11, 01-25-11 and 01-26-11 a total of 10 days.

Patient #11 was admitted 01-31-11. Nurses notes dated 01-31-11 revealed at 2200 bilateral wrist restraints were placed for patient safety. There was no physician order for wrist restraints.

Patient #12 was admitted 01-06-11. Nurses Notes reflected documentation of restraints 0700-01-08-11 to 0600-01-09-11. There was no physician order for restraints.
Nurses Notes reflected documentation of restraints 0700-01-19-11 to 0900-01-19-11, 1900-01-19-11 to 05-01-20-11. There was no physician order for the restraints. Nurses notes reflected documentation of restraints 0700-01-23-11 to 0100-01-24-11. There was no physician order for the restraints. Nurses Notes reflected documentation of restraints 0700-01-24-11 to 1300-01-24-11. There was no physician order for restraints.

Review of four of four medical records of patients with wounds revealed patient care was not provided as ordered by the physician. This failed practice had the potential to affect all patients in the hospital. The findings follow:

Patient #1 was admitted at 1300 on 08/13/11 with a primary diagnosis of multiple skin ulcers, CRF and a secondary diagnosis of severe malnutrition, obesity and diabetes mellitus. Review of the medical record revealed the following:
On 08/31/10 at 1815 it was documented unable to complete wound care passed on to PM shift.
There was no documentation of wound care to the right heel (which was ordered daily on 08-18-11) on 08-31-10, 09-01-10, 09-02-10, 09-04-10, 09-05-10, 09-11-10, 09-13-10, 09-14-10, 09-18-10, 09-19-10, 09-20-10, 09-21-10.

On 09-02-10 on the Skin/Wound Assessment it was documented R (right) heel open to air. There was no physician's order to place the right heel open to air.

It was documented on the Admission Orders dated 08-13-11 at 1300 weigh on admit and daily. There was no documentation the patient was weighed on admission or daily in the medical record.

Patient #3 was admitted 02-13-11. Admission orders dated 02-13-11 at 1015 revealed an order for Santyl to (L) left buttock ulcer BID (twice daily).
Nurses notes dated 02-13-11 at 1015 revealed Sacral wound noted ...covered with dry dressing. The 24 Hour Wound Care Plan dated 02-13-11 revealed at Physician ' s Wound Care Order: Dry drsg (dressing) to sacral until (Dr. Named) comes to evaluate. There was no physician order for dry dressing to sacral until (Dr. Named) comes to evaluate until 02-16-11 at 1100.
On 02-15-11 wound care was done only one time. On 02-18-11 wound care was done only one time. On 02-18-11 wound care was done only one time. On 02-20-11 wound care was done only one time. On 02-23-11 wound care was done only one time. On 03-01-11 wound care was done only one time.

Patient #7 was admitted 12-27-10. On the SKIN/WOUND ASSESSMENT dated 01-03-11 a dressing change (WTD (wet to dry) Dakins Solution once daily) was documented as done to L (left) groin). There was no order on the Physician Orders for a WTD dressing change with Dakins to be done daily to the left groin. Dressing changes were documented as done on 01-03-11, 01-04-11 and 01-06-11.

Patient #12 was admitted 01-06-11.
On 01-06-11 Physician Orders revealed an order for (R) right great toe and #2 t post, #4 and #5 paint with betadine daily until seen by Dr. (Named).
01-07-11-01-23-11-There was no documentation of wound care to the (R) great toe, 2tpost, #4 and #5.
01-25-11-01-26-11-There was no documentation of wound care to the (R) great toe, 2tpost, #4 and #5.
On 01-07-11 Physician Orders revealed an order for Santyl to ulcers of the legs once day and cover with dry dressing. Xerofoam Gauze to open tears on arms.
01-11-11-There was no documentation the dressing change was done on the left leg or the arms.
01-12-11-There was no documentation the dressing change was done on the left leg or the arms.
01-13-11-There was no documentation the dressing change was done on the left leg or the arms.
01-15-11- There was no documentation the dressing change was done on the (R) leg
01-16-11-Documentation revealed a dressing change was done to the BUE (bilateral upper extremities) with tegaderm and wrapped with chux. The physician orders were for Xerofoam to open tears on arms.
On 01-18-11-A physician order was written Xanaderm to sacrum bid and prn.
01-19-11-Documentation reflected no dressing due. There was no documentation Xanaderm to sacrum bid was done.
01-20-11- There was no documentation Xanaderm to sacrum bid was done. There was no documentation Santyl to ulcers on legs daily and cover with dry dressing was done. There was no documentation Xerform gauze to open tears on arms was done.
O1-21-11-There was no documentation of a dressing change done on the legs or the sacrum.
01-22-11-There was no documentation of a dressing change done on the legs or the sacrum.
01-25-11-There was no documentation of a dressing change was done to the sacrum.
01-26-11-There was no documentation of a dressing change done to the sacrum , legs or the arms.

Based on review of 14 of 14 medical records, it was determined verbal and telephone orders were used as a common practice to relate the orders of the physician. This practice had the increased potential for miscommunication that could contribute to a medication or other error that could affect all patients in the hospital. The findings follow:

Patient #1 was admitted at 1300 on 08/13/11, 59 physician orders were written. Twenty eight of 59 orders were verbal/telephone orders.

Patient #2 was admitted 12-23-10. Fifty two physician orders were written. Twenty nine of the 52 physician orders were verbal/telephone orders.

Patient #3 was admitted 02-13-11. Thirty nine physician orders were written, 25 of the 39 physician orders were verbal/telephone orders.

Patient #4 was admitted 12-30-11. Twenty physician orders were written, 10 of 20 physician orders were verbal/telephone orders.

Patient #5 was admitted 02-26-11. Four physician orders were written. Two of 4 physician orders were verbal/telephone orders.

Patient #6 was admitted 01-06-11. Twenty nine physician orders were written, 6 of 29 physician orders were verbal/telephone orders.

Patient #7 was admitted 12-27-10. Twenty one physician orders were written, 12 of the 21 physician orders were verbal/telephone orders.

Patient #8 was admitted 02-17-11. Six physician orders were written, 2 of the physician orders were verbal/telephone orders.

Patient #9 was admitted 02-26-11. Five physician orders were written, 2 of the physician orders were verbal/telephone orders.

Patient #10 was admitted 02-18-11. Forty nine physician orders were written, 32 of 49 physician orders were verbal/telephone orders.

Patient #11 was admitted 01-31-11. Twenty physician orders were written, 17 of the 20 physician orders were verbal/telephone orders.

Patient #12 was admitted 01-06-11. Fifty physician orders were written, 35 of 50 physician orders were verbal/telephone orders.

Patient #13 was admitted 11-01-11. Sixty eight physician orders were written, 29 of 68 physician orders were verbal/telephone orders.

Patient #14 was admitted 01-17-11. Seventy two physician orders were written, 51 of 72 physician orders were verbal/telephone orders.