HospitalInspections.org

Based on review of review of facility documents, medical records, and staff interview (EMP), it was determined the facility failed to administer treatments as ordered by a practitioner for five of 17 medical records reviewed (MR15, MR16, MR17, MR18, and MR19).


Findings include:



Review of facility policy, Wound Program Overview and Initiation Process, last revised April 1, 2014, revealed, " ... Purpose: Hospital establishes guidelines for the initiation of wound care for new admissions and the on-going management of wound patients. ... 6. Standardized wound algorithms are available in the wound care manual. A physicians order is required to implement wound algorithms."

Review of MR15 revealed the patient was admitted on June 16, 2016 with wound care orders for a sacral wound dressing twice a day. Further review of MR15 revealed documentation the dressing was changed only once a day on June 18, June 19, June 21, June 22, June 29, June 30, July 1, July 2, July 3, and July 4, 2016. No documentation of a dressing change was observed for June 20, June 25 through June 28, and July 5, 2016.

Review of MR16 revealed the patient was admitted on August 5, 2016 with daily wound care orders for a skin tear. Further review of MR16 revealed no documentation of wound care on August 13, August 14, August 16, August 24, August 25, August 27, August 28, August 30, and September 1, 2016.

Review of MR17 revealed the patient was admitted on June 8, 2016 with wound care orders for an intergluteal dressing change daily. Further review of MR17 revealed no documentation of wound care on June 11, June 12, June 18, June 20, June 22, June 24, June 25, June 26, July 2, July 3, July 7, July 8, and July 9, July 15, July 16, and July 19, 2016.

Review of MR18 revealed the patient was admitted on August 10, 2016 with wound care orders for abdominal incision care twice a day. Further review revealed documentation that wound care was provided only once a day on August 11, August 15, August 16, August 17, August 18, August 25, August 26, August 28, August 31, and September 1, 2016. No documentation of abdominal wound care was observed on August 24, and August 29, 2016.

Review of MR19 revealed the patient was admitted on September 2, 2016 with orders for sacral wound care on Monday, Wednesday, and Friday. Further review revealed no documentation of sacral wound care on Monday, September 5, Wednesday, September 7, Monday, September 12, and Wednesday, September 16, 2016.

Interview with EMP1 on November 3, 2016, at 11:00 AM confirmed the above findings and revealed, "We know we are having issues with wound care and have hired a wound care nurse who is in orientation."

Based on a review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the patient's medical record contained sufficient information to justify the diagnosis and treatment, and to document the results accurately for one medical record reviewed (MR1).


Findings include:


Review of facility documentation "Medical Staff Rules And Regulations" dated March 17, 2016, revealed "C. Medical Records 1. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient."


Review of facility documentation "Documentation Standards" revised October 1, 2016, revealed "Procedure: ... 3. All entries must be legible."


1. Review of MR1 revealed physician progress notes dated Ocotber 4, 5, 6, 7, 8, and 10, 2016, that was not legible.


Interview with EMP1 on October 31, 2016, at approximately 11:20 AM confirmed the above findings and revealed 'I can't read it."


Interview with EMP 4 on October 31, 2016, at approximately 11:40 AM confirmed the above findings and revealed "Doctor ... fills in for Doctor ... when he is here you can't read it[physician daily notes]."


2. A request was made to have the physician review and decipher the notes on October 31, 2016, at approximately 11:50 AM. Another request was made on November 3, 2016, at approximately 9:40 AM to review the notes and none was provided.


Interview with EMP1 on November 3, 2016, at approximately 10:00 AM confirmed the above findings and revealed "We called his office, we haven't received anything."