HospitalInspections.org

Based on record review and interview it was determined nurse staffing was not adequate to provide the nursing care to all patients as needed. Fourteen of 22 patients with wounds, from a total census of 30, were not assessed for or did not receive wound care as ordered by the physician. The findings follow:

A. Patient #1-admitted 04/21/10 with respiratory failure. There was no documentation regarding a pressure ulcer until 04/26/10 although documentation on the 24 Hour Patient Record and Plan of Care reflected the patient was repositioned every two hours (from admission on 04/21/10 until discharge 04/28/10) and was given a bath daily from 04/23/10 until discharge 04/28/10). There was no evidence from 04/21/10 till 04/26/10 nursing staff notified the physician of the patients wounds. It was documented on the Progress Notes 04/26/10-Stage III decubiti-Stage III breakdown Sacrum-small wound dehiscence on thigh. It was documented on the Physician's Orders on 04/26/10 Wound care to sacrum and L (left) thigh and on 04/27/10 NS (normal saline) WTD (wet to dry) DRSG (dressing) to sacrum and L(left) inner thigh daily. The patient was transferred to another facility 04/28/10.

Patient #2 was admitted 03/29/10 for wound care. On 04/22/10 an order was written on the Physician's Orders at 1340 for wet to dry dressing with normal saline BID (twice a day) start Sunday to sacral wound. On the Nursing Wound Documentation sheet it was documented Wet-to dry with normal saline Start Sunday 04/25/10 BID (twice a day). There was no evidence wound care was done BID as ordered on 04/25/10, 04/26/10, 04/28/10, 04/29/10, 04/30/10, 05/01/10 and 05/02/10.

Patient #3 was admitted 03/16/10 for wound care and malnutrition. The Physician ordered Right ankle and left heel (Stage II ulcers) clean daily with Saline and dress with Xeroform gauze then dry gauze on 03/23/10. There was no evidence wound care was done on the right ankle on 04/02/10, 04/07/10, 04/09/10 and 04/18/10. There was no evidence wound care was done on the left heel 04/01/10, 04/02/10, 04/03/10, 04/06/10, 04/07/10, 04/08/10, 04/09/10, 04/10/10, 04/11/10 and 04/18/10.
The Physician ordered Stage IV right ischial wound clean with clorpactin 0.42 solution and pack with same. There was no evidence wound care was done on the right ischial 03/22/10, 04/01/10 and 04/02/10.

Patient #4 was admitted 04/06/10. The physician ordered apply Xenaderm to back and sacrum BID (twice daily) on 04/07/10 at 1610 on the Physician ' s Orders Form. There was no evidence wound care was done as ordered Xeroderm was applied to the back BID on 04/07/10, 04/08/10, 04/ 09/10, 04/10/10, 04/11/10, 04/12/10, 04/13/10, 04/14/10, 04/15/10, 04/16/10, 04/17/10, 04/18/10, 04/19/10, 04/20/10, 04/21/10, 04/22/10, 04/25/10 and 04/26/10. There was no evidence Xeroderm was applied to the sacrum BID on 04/07/10, 0408/10, 04/09/10, 04/10/10, 04/11/10, 04/12/10, 04/13/10, 04/14/10, 04/15/10, 04/16/10, 04/17/10, 04/18/10, 04/19/10, 04/20/10, 04/21/10, 04/22/10, 04/24/10, 04/30/10, 05/01/10, 05/02/10 and 05/03/10.

Patient #5 was admitted 04/12/10 for wounds. The physician ordered wet to dry dressing change with ? strength Dakins BID (twice daily). There was no evidence the dressing change was done BID (twice daily) as ordered to the left hip on 05/03/10.

Patient #6 was admitted 03/26/10. The Physician ordered on 03/26/10 apply ? Dakins wet to dry t Sacrum BID (twice daily) and as needed. There was no evidence the dressing change was done as ordered BID on 04/01/10.

Patient #7 was admitted 04/02/10 for wounds and ESRD (End Stage Renal Disease). The Physician ordered on 04/02/10 at 1115 apply Santyl to right hip, right scrotum and penis BID and as needed. Cover with dry 4x4 and paper tape. There was no evidence wound care was done BID (twice daily) as ordered on the right hip on 04/03/10, 04/05/10, 04/06/10, 04/08/10, 04/09/10, 04/10/10, 04/11/10, 04/12/10, 04/13/10, 04/14/10, 04/15/10, 04/16/10, 04/17/10, 04/18/10, 04/19/10, 04/20/10, 04/21/10, 04/23/10, 04/24/10, 04/25/10, 04/26/10, 04/27/10, 04/28/10, 04/29/10, 04/30/10, 05/01/10, 05/02/10 and 05/03/10. There was no evidence wound care was done BID (twice daily) as ordered on the penis on 04/02/10, 04/03/10, 04/04/10, 04/05/10, 04/07/10, 04/08/10, 04/09/10, 04/10/10, 04/11/10, 04/12/10, 04/13/10, 04/14/10, 04/15/10, 04/16/10, 04/17/10, 04/18/10, 04/19/10, 04/20/10, 04/23/10, 04/24/10, 04/25/10, 04/27/10, 04/29/10, 04/30/10, 05/01/10, 05/02/10 and 05/03/10.

Patient #8-was admitted 03/25/10 for respiratory failure. The Physician ordered on 03/26/10 at 1245 apply foam border to Sacrum every three days and as needed. There was no evidence that reflected the foam was applied as ordered on 04/04/10

Patient #9-was admitted 03/10/10 for skin ulcer/wound. The Physician ordered on 03/13/10 wet to dry dressing change to scrotal wound BID (twice daily). There was no evidence the dressing change was done as ordered on 03/15/10, 03/16/10, 03/17/10, 03/18/10, 03/20/10, 03/21/10 and 03/22/10. On 04/01/10 the Physician ordered daily wound dressing to scrotum-clean with saline-dress wounds with Safgel and Xerofoam there was no evidence the dressing change was done as ordered on 04/09/10, 04/25/10 and 05/01/10.

Patient #10 was admitted 04/27/10 for wound care. The Physician ordered on 04/29/10
normal saline wet to dry to Left ischium and Left groin BID (twice daily) and as needed. There was no evidence wound care was provided as ordered on 05/01/10.

Patient # 11 was admitted for wound care on 04/08/10. The Physician ordered on 04/09/10 Right and left shin and sacrum apply ? Dakins daily and as needed. There was no evidence wound care was provided as ordered to the right lateral shin on 04/10/10 and 04/24/10. There was no evidence wound care was provided to the left lateral shin
04/20/10 and 04/30/10.

Patient #12 was admitted 03/02/10. The Physician ordered on 03/31/10 Tegaderm absorbent to right posterior thigh and left gluteal ever 7 days and as needed. There was no evidence wound care wad provided as ordered to the right posterior thigh 04/07/10.

Patient #13 was admitted 04/13/10 for decubitus ulcer, infected amputation stump, sacral decubitus Stage III and paraplegia. The Physician ordered on 04/14/10 to sacral wound Stage III clean wound area daily with clorpactin 0.4% solution, then apply santyl to eschar and wet to dry dressing with clorpactin solution. There was no evidence wound care was provided as ordered on 04/14/10, 04/15/10, 04/17/10 and 04/25/10. The Physician ordered on 04/14/10 to clean left above the knee amputation with normal saline cover with dry 4x4s kerlix ace wrap daily and as needed. There was no evidence the wound care was done as ordered on 04/14/10, 04/15/10, 04/17/10 and 04/25/10.

Patient #14 was admitted 03/24/10. The Physician ordered on 03/24/10 to apply foam border to sacral wound every third day and as needed. There was no evidence the wound care was done as ordered on 03/26/10, 03/27/10, 03/28/10, 04/03/10, 04/04/10, 04/05/10, 04/08/10, 04/14/10, 04/17/10, 04/22/10, 04/29/10, 05/02/10 and 05/03/10.

B. The findings in the medical records were verified 1615 on 05/05/10 with the Director of Clinical Services and the Director of Quality the quality of care issue was confirmed.