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SELECT SPECIALTY HOSPITAL SOUTH DALLAS
CONTENT OF RECORD: DISCHARGE SUMMARY
Tag No.: A0468
Based on interview and record review, the hospital failed to ensure the physician discharge summary for 1 of 3 records reviewed [Patient #1's] addressed a hospital acquired pressure ulcer to the left ear.
Findings Included:
1) The physician discharge summary dated 04/23/10 timed at 0832 reflected the medical diagnosis were, End Stage Renal Disease, Hemodialysis, Intravenous Line-related Sepsis, Severe Hyperglycemia, Type II Diabetes, Dyslipidemia, Anemia, Renal Osteodystrophy, Bleeding Arteriovenous shunt, Rectal Bleeding, Prostate Cancer, Delirium, Dementia, Cerebrovascular Accident, Osteoarthritis and Degenerative Joint Disease, Debility and Gastroesophageal Reflux Disease.
The nursing wound documentation reflected, Patient #1 was admitted with a Left Medial Heel Pressure Ulcer and a Gluteal Crease Pressure Ulcer. The patient was provided treatment and a left heel boot was applied.
The photographic wound documentation dated 03/22/10 reflected, Patient #1 "developed an unstageable pressure ulcer to the left ear..."
On 07/16/10 at approximately 2:00 PM RN #3 was interviewed. RN #3 was asked to review Patient #1's discharge summary. RN #3 stated no documentation was found indicating Patient #1 had a pressure ulcer to the left ear.