HospitalInspections.org

Based on hospital policy and procedure review, medical record review and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to assess and provide interventions for 3 of 4 sampled patients with wound dressing change and Ostomy irrigation orders (Patient #10, #4 and # 2).

The findings include:

Review of the Hospital's Policy titled "Advanced Wound Care Dressing", revised 10/2015 revealed "V. Intervention for Wound Dressing Changes...K. Apply dressing as ordered."

1. Open medical record review on 09/28/2016 for Patient #10 revealed a 44 year old female admitted on 09/14/2016 at 1145 with a diagnosis of "T5 (Thoracic-Chest area Spine Fifth spinal cord level) ASIA (American Spinal Injury Association) A (classification of spinal injury)...secondary to gunshot wound". Review of Physician's Orders dated 09/14/2016 at 1953 revealed an order to apply an antiseptic, cover wound with abdominal pad and wrap with kerlix dressing daily. Review of nursing notes revealed documentation of a dressing change on 09/14/2016 at 1930 and on 09/15/2016 at 1910. Further review of Physician's Orders dated 09/15/2016 at 1913 revealed an order to apply medi-honey (wound healing medication) to slough, apply antiseptic, cover wound with abdominal pad and wrap with kerlix dressing every 12 hours. Review of nursing notes revealed documentation of a dressing change on 09/16/2016 at 2000 (24 hours and 40 minutes since last dressing change), on 09/17/2016 at 0800, on 09/19/2016 at 0800 (48 hours since last dressing change) and 2000, on 09/20/2016 at 0818, on 09/21/2016 at 0800 (23 hours and 42 minutes since last dressing change), on 09/22/2016 at 1100 (27 hours since last dressing change), on 09/23/2016 at 0800 (16 hours since last dressing change) and 2000, on 09/24/2016 at 0800, on 09/25/2016 at 0900 (25 hours since last dressing change) and on 09/26/2016 at 1707 (20 hours and 7 minutes since last dressing change). Review of Physician's Orders dated 09/26/2016 at 1718 revealed an order to apply foam dressing daily as needed. Review of nursing notes revealed documentation on 09/26/2016 at 1707 that foam dressing was applied.

Interview on 09/28/2016 at 1610 with Wound and Ostomy Care Nurse (WOC #1) revealed the nursing staff are expected to change the wound dressing as per the physician's orders. Interview revealed the nursing staff did not follow the hospital's policy for wound care dressing changes. Interview confirmed the findings.


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2. Open medical record review of Patient # 4 revealed an 81 year old female admitted on 9/13/2016 with a diagnosis of debility secondary to high grade urothelial carcinoma (cancer in the urinary system) of the bladder, status post cystectomy with ileal conduit (urinary drainage system). Review of the physicians orders revealed "Ostomy Care (Nsg) 09/14/16 17:30 EDT Routine 2x/ Wk WSa ( daily on Wed and Sat) Urostomy 2 piece 2 1/4 applianceWed-Sat and prn ( as needed)..." Review of Nursing documentation revealed dressing change completed on 09/14/2016 at 1730 (Wednesday) and 09/21/2016 at 1730 (Wednesday). Record review revealed no dressing changes documented for 09/17/2016 (Saturday) or 09/24/2016 (Saturday) as ordered by the physician.

Interview on 09/28/2016 at 1610 with Wound and Ostomy Care Nurse (WOC #1) revealed the nursing staff are expected to change the wound dressing as per the physician's orders. Interview revealed the nursing staff did not follow the hospital's policy for wound care dressing changes. Interview confirmed the findings.

3. Closed medical record of Patient #2 revealed a 59 year old male admitted on 8/9/2016 with a diagnosis of bladder cancer status post radical cyctoprostatectomy (removal of the urinary bladder and prostate glands) with Indiana Pouch (urinary diversion) formation and complicated post operative course with subsequent debility. Review of physician's orders revealed "Nursing Misc Communication 08/09/16 15:00 EDT flush with sterile saline and aspirate Mitrofanoff catheter q (every) 3h (hours)." Review of Nursing documentation revealed irrigation done on 08/09/2016 at 555 and no documented irrigation of the catheter on 08/10/2016, 08/11/2016 and irrigation done on 08/12/2016 at 2100, on 08/13/2016 at 0100, 0600, 0524 and 0753. Review revealed irrigation completed on 08/14/2016 at 1000, 1300, 1600, 2100 and on 08/15/2016 at 0100 and 0500. Review of Physician Progress Note on 08/15/2016 at 1128 revealed "...of note, daughter reported that over the weekend his mitrofanoff tube was flushed using tap water. Per my discussion with Urology today, this is ok..." Review of medical record revealed no documentation of irrigation on 08/16/2016. Record review revealed physician orders on 08/17/2016 at 11:24 EDT " patient is to be encouraged to in and out cath himself, not his wife. To empty channel q 3 hrs. To flush channel with 30-60 of normal saline BID (twice daily). Record review revealed no documentation of flushing or irrigation on 08/17/2016, 08/18/2016, 08/19/2016, 08/20/2016, 08/21/2016, 08/22/2016 and 08/23/2016. Review of Nursing documentation on 08/24/2016 at 2000 revealed "wife managed pouch." Record review revealed no further documentation of irrigation or flushing of the pouch from 08/25-31/2016. Record review revealed the patient was discharged home on 08/31/2016.

Interview with Registered Nurse (RN) on 09/28/2016 at 1445 revealed she cared for Patient # 2 on several occasions and she never flushed his catheter. Interview revealed the patient's wife cared for the catheter and performed all flushing and irrigation. Interview revealed she did not document the times the wife performed the flushing in the medical record. Interview revealed she was not familiar with the Indiana pouch and the wife taught her how to perform the flushing of the catheter. Interview revealed she did not give the wife any supplies to perform the flushing or irrigation of the catheter.

Interview on 09/28/2016 at 1615 with WOC #1 revealed it is the expectation of the nursing staff to document the flushing of the catheter no matter who performs the task.