HospitalInspections.org

Based on a review of documentation and the clinical record for patient #1, the care of each patient was not assigned to nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. Failure to do so can result in patient harm.

Findings were:

The admission assessment for patient #1 was completed jointly by staff #4 (a Licensed Vocational Nurse) and staff #5 (a Registered Nurse). In the "gastrointestinal" portion of the assessment, no surgery or procedure was indicated in the box present for such, although patient #1 had undergone a recent colostomy and also had a separate abdominal surgical incision. The integumentary (skin) portion of the assessment also lacked any mention of a surgical incision.

The admission orders for patient #1 stated, in part: "Continue current wound care to affected area/site.", although no current wound care orders were specified in the information from the transferring hospital. The clinical record contained no documentation that the order had been clarified or that additional information needed to complete the wound care orders had been sought. An order clarifying wound vacuum change specifics was written on Sunday, April 19th, stating that wound care was to be performed every Monday and Thursday, although the first wound care with dressing change was not performed until Tuesday, 4-21-15. No explanation was found that provided a reason for the delay in carrying out the order.


Review of a document provided (stated to be an "informal guide" by staff #1) titled "Wound Vac Competency Check Off List" revealed the following statement:
"Determine that there are orders for a wound vac change ..."

The above was verified in an interview with the Director of Nursing and the Chief Quality Officer on the afternoon of 7-8-15 in the facility conference room.