HospitalInspections.org

Based on medical record review and interview, the hospital failed to ensure nursing followed physician's orders for wound cultures for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Medical record review for Patient #1 revealed an admission date of 12/5/18 with diagnoses which included Chronic Anemia, Osteoarthritis, Chronic Diastolic Congestive Heart Failure, Aspiration Pneumonia and Hypoxemic Respiratory Failure.

A physician's order dated 1/28/19 revealed, "...Wound culture...Left posterior knee drainage..."

A physician's order dated 1/30/19 revealed, "...Wound culture...on 1/30/19..."

A Wound Progress Note dated 1/28/19 revealed, "...Wound Location Orientation: Left; Posterior...Wound Length...2 cm [centimeters]...Wound Width...1 cm...Wound Depth...3 [cm]...Periwound Skin Color...Dark red or purple and/or non-blanchable...Exudate Type...Purulent...Exudate Amount...Large...Signed...[Wound Care Nurse #1] ..."

A physician's progress note dated 1/31/19 revealed, "...Culture [wound] data still pending. It appears that the 1st culture [1/28/19] may never have gotten to the lab..."

There was no documentation a wound culture was sent to the lab on 1/28/19 or 1/30/19, and there was no documentation of wound culture results in Patient #1's medical record.

2. During an interview in the Education Room on 5/8/19 at 9:20 AM, Physician #1 confirmed wound cultures for Patient #1 were ordered twice, but the hospital did not receive any results from either wound culture order.