HospitalInspections.org

Based on document review and interview, the facility failed to ensure that all patient orders were complete and authenticated.

Findings:

Review of the facility's Policy# C32II Physician Orders with Patient Instructions and a Wound Clinic's patient's medical record, the Physician Order and Patient Instruction sheet did not include the frequency and type of dressing changes needed. Specifically, a 78 year-old patient was seen in the Wound Care clinic on 3/19/10 for stasis ulcers on her lower legs. On that day an order for Triaminiclone cream and tubi grips to her right and left calf was written and given to the Home Care agency. When asked by the Home Care agency on 3/22/10 for clarification of when and what type of dressings should be applied, the clinic nurse wrote the clarification on the original order sheet (dated 3/19/10) and faxed it to the agency on 3/22/10. The signatures on the order sheet, by the physician, nurse and patient were dated 3/19/10. There was no indication as to the date and by whom the form was altered to include: daily dressing change and apply dry absorptive dressing to both lower legs.

This was confirmed on interview with the Clinic's Coordinator on 4/5/10 at 0900.