HospitalInspections.org

Based on patient medical record review and staff interview, the nurse executive/chief clinical officer, failed to ensure that nursing staff obtained an order for wound care for two patients (#1 and #4), and failed to ensure that nursing staff documented wound dressing changes per physician orders for three patients. (pts. #3, #4, and #5)

Findings:
1. review of patient medical records on 5/17/13, indicated:
a. pt. #1 had:
A. documentation by the admitting nurse on 3/1/13 of the application of a wound vac to an abdominal wound
B. documentation in physician progress notes of the presence of a wound vac to the patient's abdominal wound
C. no order by the physician for wound vac treatment/care

b. pt. #3 had:
A. an order on 3/8/13 to "Cleanse wound L subclavian with saline cut hydrofera blue dressing to size of wound and wet with saline squeeze out excess moisture and place in wound bed secure with clear film dressing change every 24 hours"
B. no documentation of a daily dressing change on the "Treatment Administration Record" form on 3 3/9/13
C. no "Treatment Administration Record" form for the week of 3/10/13 to 3/16/13
D. no documentation of a daily dressing change on the "Treatment Administration Record" form on 3/17/13, 3/18/13, 3/19/13, 3/20/13, 3/21/13, or 3/22/13 (3/18/13 and 3/22/13 were noted by the wound nurse in the "Progress Notes" of the chart)

c. pt. #4 had:
A. orders written by the wound nurse on 3/25/13 for wound care (authenticated by the admitting physician) that lacked specificity of frequency for dressing changes
B. had notation on the "Treatment Administration Record" form that the dressing changes were every 3 days
C. lacked nursing documentation of the every three day dressing changes on 3/31/13 and 4/3/13 on the
"Treatment Administration Record" form

d. pt. #5 had:
A. an order written 2/21/13 that read: "...Sacral area cleanse with saline pat dry and apply sacral optifoam dressing" ("Treatment Administration Record" forms in the medical record indicated dressing changes every three days)
B. no "Treatment Administration Record" form for the weeks of 3/10/ to 3/16/13 and 3/17/13 to 3/23/13 making it impossible to determine if dressing changes for the sacral area occurred as per physician orders

2. Interview with staff member #55, the medical records manager/director, at 11:45 AM and 2:30 PM on 5/17/13 indicated:
a. nursing staff are sometimes noting in the nurses' notes information related to dressing changes
b. documentation is not consistent as to when dressing changes occur
c. the "Treatment Administration Record" form is the appropriate place for wound care/dressing changes to be noted by nursing staff and that documentation is lacking as listed in 1. above
d. there is no physician order for the wound vac for pt. #1 and no order for how often to change dressings for pt. #4

3. Interview with staff member #52, the chief clinical officer, at 12:50 PM on 5/17/13 indicated:
a. documentation is not consistent as to when dressing changes occur
b. the "Treatment Administration Record" form is the appropriate place for wound care/dressing changes to be noted by nursing staff and that documentation is lacking as listed in 1. above
c. there is no physician order for the wound vac for pt. #1 and no order for how often to change dressings for pt. #4