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Based on record review and interview the facility failed to ensure physician orders for wound care, weights and dietary supplements were carried out as ordered, for one (1) patient cited in a complaint Patient (G).


Findings:

Patient (G)

Review of discharge summary for Patient G revealed the patient was admitted to the facility on the evening of 7/16/2012 and was discharged on the morning of 8/2/2012. The patient had multiple medical conditions including recent amputation for gangrene.
Review of admission assessment documentation for Patient (G) revealed the patient had left below the knee amputation, amputation of right great toe and second toe. There was documentation that the Pinky toe was discolored.

Review of photographs dated 7/16/2012 day of admission showed the left extremity had a below the knee stump wrapped in dressing.
The right great toe stump was also wrapped in dressing. The second toe was open to air with what appeared to be sutures/staples. The picture also showed a semi healed pressure ulcer on the buttocks opened to air.

Review of physician orders dated 7/16/2012 revealed orders for daily wound care. The order did not specify what care was required and for which wound site. There was no documentation that staff clarified the wound care order.

There was one documentation of dressing change done on 7/19/2012 , three days after the order was written .
There was no other documentation that the wounds were assessed or that the daily wound care was done except for the documentation on 7/19/2012.

Review of physicians orders dated 7/17/2012 at 9:00 am revealed an order for Ertapenem (antibiotic) one (1) gram/100 ml and 100mls normal saline daily.

There was no documentation that the patient received the medication on 7/17/2012 and 7/18/2012. There was no reason for the omission documented in the patient's record.

Further review of medication administration record revealed documentation that the patient was given the medication on 7/19/2012 and 7/20/2012. There was no documentation that the medication was administered on 7/21/2012 - 7/29/2012. There was no stop order, or indication that the patient was not in the facility. There was documentation that the medication was administered on 7/30/2012 through 8/1/2012. The patient was discharged on 8/22012.

Review of physician orders revealed an order dated 7/26/2012 for a nutritional supplement Glucerna one can to be given three (3) times a day. There was no documentation that the patient ever received the supplement.

Review of admission orders dated 7/16/2012 revealed an order for the patient to be weighed weekly. There was documentation of an admission weight 7/16/2012.

There was no documentation that the patient was weighed week of July 23, 2012 or week of July 30, 2012.

During an interview on 11/9/2012 at 12: 20 pm with the Nurse Manager she stated the nurses should clarify wound orders and wound assessment is required. She stated she could not tell why the patient missed several days of antibiotics.

Review of the facility's policy/procedure manual dated 11/30/11 documented for wound assessment:
" All patients will have integument and wound inspection daily, weekly, and as often as indicated''.

Based on record review and interview the facility failed to ensure a nursing plan of care that addressed the individual care needs of patients was developed ,evaluated and revised for a patient with multiple medical conditions including multiple amputated limbs;
Failed to implement it's wound care policy which require care planning for patients at risk for pressure sore or with wounds, citing one (1) patient cited in a complaint Patient (G).


Findings:

Patient (G)

Review of discharge summary for Patient G revealed the patient was admitted to the facility on the evening of 7/16/2012 and was discharged on the morning of 8/2/2012. The patient had multiple medical conditions including recent amputation for gangrene, Diabetes and Hypertension.

Review of admission assessment documentation for Patient (G) revealed the patient had left below the knee amputation, amputation of right great toe and second toe. There was documentation that the Pinky toe was discolored. There was documentation the patient had a stage three (3) sacral decubitus ulcer.
Review of skin assessment documentation revealed a Braden Scale skin assessment done for the patient was scored as (17) and (13) which was high risk for pressure ulcer development or worsening. hemoglobin was 8.7 (low). Patient G was on an ADA 1800 calorie diet and was to be given nutritional supplement three times a day.

Review of the nursing care plan revealed there was no care plans developed to address the patient's wounds and pressure ulcer. There was no care plan to address the patient's nutrition status.

Review of facility's current policy and procedure on Wound Care dated 11/30/20111 directed staff as follows:
" All patients admitted to Health South will be screened within 24 hours for risk of skin breakdown and for alteration in skin integrity by a registered nurse, utilizing the Interdisciplinary Assessment.
For a Braden score of 18 or less the skin Breakdown Prevention Protocol ( as described in this policy ) will be initiated and incorporated into the plan of care."
" Assessment : All patients will have integument and wound inspection daily, weekly and as often as indicated.
(1) assess all patients for risk of skin breakdown using the Braden scale. Record findings: Admission on the Interdisciplinary Assessment , Weekly on the plan of care."

During an interview on 11/9/2012 with the Nurse Manager she stated the Nursing staff would be in-serviced.