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Based on medical record review and interview, it was determined the Hospital failed to ensure wound care was provided in accordance with physician orders and skin assessment was not performed per policy for patients with splints. This systemic practice has the potential to affect all of those patients requiring wound care. Findings include:

1. The Hospital failed to ensure all wound care was provided in accordance with physician orders and skin assessment was not performed per policy for patients with splints. See deficiency cited at A-395.

2. The Hospital failed to ensure the Plan of Care was initiated or revised to reflect the patient's wound care needs. See deficiency cited at A-396.

3. The Hospital failed to ensure wound care was provided with a physician order. See deficiency cited at A-406.

A. Based on medical record review and interview, it was determined for 3 of 10 (Pts #7, #8, #9) patients with wounds, wound care was not provided in accordance with physician orders. Findings include:

1. Pt #7 was admitted to the hospital on 12/7/13 at 7:00 AM with the diagnosis chronic obstructive pulmonary disease (COPD). The medical record was reviewed on 1/14/14 at 3:00 PM with E6. On 12/7/13 at 4:50 PM, ICU nursing documentation stated "... Mepilex border placed on left buttock due to draining blood, gauze placed in groin folds... physician notified" No physician order was written. On 12/10/13 at 10:57 AM, the physician order stated Mepilex border foam to left posterior thigh and left groin wounds every Tuesday. On 12/10/13 at 11:14 AM, WON documentation stated the presence of third wound on the left posterior thigh with no dressing selection noted and the presence of skin breakdown in folds of abdomen with dressing selection of Mepilex Border foam to the right and left locations, as well at Miconazole powder. There was no order for the application of Mepilex to the right groin.

2. Pt #8 presented to the ED on 12/17/13 at 8:41 AM with the CC "cut foot on broken glass" and was admitted to the hospital for observation with wounds and was discharged home with Home Health on 12/20/13. The medical record of Pt #8 was reviewed on 1/15/14 with E6. On 12/17/13 at 2:16 PM, there were physician orders for wound care nurse consult with subsequent orders for cleansing and dressing of burns on the right and left legs of Pt #8 daily. There was no documentation of Pt #8's wounds being cleansed and/or dressings being changed on 12/19/13 or 12/20/13.

3. Pt #9 was a direct admit from the physician office to the hospital on 12/17/13 with the diagnoses gangrene right foot and cellulitits and required wound care. On 12/20/13, Pt #9 underwent a right below the knee amputation. The medical record of Pt #9 was reviewed on 1/15/14 with E6. On 12/17/13 at 7:48 PM, nursing documentation stated "wound culture collected"; however, there is no documentation to state whether the dressing was removed, wound cleansed, and/or what dressing was applied. There was no order for a dressing change. On 12/18/13 at 12:04 PM, there was a physician order for daily wound care to the right 1st and 2nd toes using Melgisorb and bulky dressing. There was no nursing documentation of a wound dressing change on 12/19/13. On 12/23/13 at 9:25 AM
there was a physician order for daily dressing change using 4x4 and kerlix. On 12/25/13, nursing documentation stated Pt #9's dressing was changed 3 times between 7:50 AM and 6:44 PM. There was no documentation the surgeon was notified of the need to change the dressing more than daily.

4. An interview was conducted with E6 on 1/15/14 at 3:00 PM. E6 reviewed the medical records of Pts #7, #8, and #9 and confirmed the wound care was not provided in accordance with physician orders.


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B. Based on review of policy, 2 of 2 (Pts #1, #5) record review and staff interview it was determined skin assessment was not performed per policy for patients with splints.
Findings include:

1. The policy titled "Skin Breakdown Prevention and Identification" (revised 3/16/13) was reviewed 1/15/14. It stated "...Patients are assessed for risk of pressure ulcer development on admission, every shift, transfer and discharge...patients seen in the... ER (Emergency Room)...are considered high risk."

2. The medical record of Pt #1 was reviewed on 1/14, 1/15, and 1/1714. It indicated Pt #1 presented to the Hospital's ED on 11/17//3 with complaint of multiple blunt injuries from a tornado. Documentation indicated that in the ED, Pt #1 had a wound to the right backside leg cleaned and dressed. Due to a fracture near the ankle of the right leg, a splint was applied and secured with an ACE wrap. Subsequently, Pt #1 was admitted to the Med/Surg floor. There was no documentation in the nurses notes on the Med/Surg floor, from 11/17/13 to 12/5/13, that the splint to the backside of Pt #1's right leg was ever removed and the skin assessed.

3. A record review for Pt #5 was conducted 1/14/14. Pt #4 was admitted through the ER on 1/15/14 with a right leg fracture which was splinted. The right leg skin assessment was not completed during the admission and shift skin assessment by the nurses. The Nurses wound assessment notes from 1/11/14 at 7:51 PM through 1/14/14 at 9:45 AM stated there were no wounds noted. The wound assessment dated 1/14/14 at 4:19 PM stated "patients leg is splinted due to fracture, unwrapped bandage to check skin... abrasion on right knee from fall..." A physicians order dated 1/14/14 at 5:43 PM stated "do not remove the splint."

4. During an interview with the Nurse Manager of Orthopedics (E9) on 1/15/14 at 11:15 AM, it was stated the nurse took Pt #4's splint off to perform a skin assessment of the right leg, called the physician to report the abrasion and received an order not to remove the splint because surgery was scheduled for 1/15/14. E9 stated the right leg skin assessment was not performed by the nursing staff 1/11/14, 1/12/14 and 1/13/14 and an order to not remove the splint was not received for 3 days. E9 stated the nurse should have clarified with the physician upon admission right leg fracture treatment/assessment care. E9 stated "we don't take splints off if the fracture is unstable but we should always obtain an order for that.. this was not an unstable fracture" then stated there was no policy or protocol about when to remove or not to remove splints for skin assessment.



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Based on record/document review and staff interview, it was determined that in 1 of 2 (Pt #6) medical records reviewed, the hospital failed to ensure all entries in the discharge orders were accurate.

1. Patient #6 medical record was reviewed with E6 (Clinical Documentation Improvement Specialist) on 01/14/14 at 2:00pm. Patient #6 presented to ED (Emergency Department) on 12/11/13 with right side weakness. Patient #6 was subsequently admitted to the Hospital on 12/11/13 with a diagnosis of CVA (Cardiovascular Accident). Medical records state that Patient#6 had wounds on back of thigh (no indication which thigh) and left ankle, as well as, redness on patient # 6 abdominal, groin, and right ankle areas. Patient #6 was seen by E5 (Inpatient Wound Care Nurse) on 12/11/13. Subsequent to the consult by E5, the following Doctor's orders were documented on 12/11/13, in patient#6 medical record: Mepilex Foam to both lateral ankles and Miconazole 2% powder to abdominal folds and groin BID (twice a day). Patient was receiving these treatments up to her discharge from the Hospital to a local Nursing Home on 12/14/13. Patient #6 discharge papers titled: "Physicians Orders-Admission Orders-Skilled Care/Nursing Home did not address patient #6 wounds or any wound orders. The area under "Wound Care" on the discharge form is blank.

2. Reviewed Hospital policy titled "Hand-off Communications" on 1/15/14. Policy states "Transfer of a patient to another hospital, nursing home, or home health agency: ...... "A complete form is defined as having all areas filled in either with pertinent information or with a line drawn through to indicate not applicable."

3. Conducted an interview with E6 on 01/14/14 at 2:30pm. E6 confirmed patient # 6 discharge papers did not acknowledge the wounds or contain any wound orders.

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Based on policy, 5 of 9 (Pts #1, #4, #7, #8, #9) record reviews and staff interview, it was determined the Plan of Care was not initiated or revised to reflect the patient's wound care needs. Findings include:

1. The policy titled "Plan of Care" (revised 8/30/13) was reviewed 1/15/14. It stated "Patients will have an initial Plan of Care developed by an Registered Nurse (RN), based on their individual needs...will be evaluated each calendar day and as needed with condition changes."

2. The policy titled "Skin Breakdown Prevention and Identification" (revised 3/16/13) was reviewed 1/15/14. It stated "...patient's will be assessed for potential and actual skin impairment... on admission, every shift, transfer and discharge...documented in the Wound Assessment tab..."

3. The medical record of Pt #1 was reviewed. It indicated that Pt #1 presented to the ED on 11/17/13 with a diagnosis of multiple wounds and fracture due to tornado. Documentation indicated that Pt #1 had a wound to the back of the right leg and a fracture to the lower end of the right leg. There were multiple other wounds sustained by Pt #1. A dressing dressing was applied to the wound, then a splint was put in place over the dressing and held in place with and ACE wrap. There was no documentation in the nursing care plan that included the care of any of the wounds sustained by Pt #1. Documentation indicated that the wound to the back of the right leg was never removed, assessed, and/or redressed.

4. A record review for Pt #4 was conducted 1/14/14. Pt #4 was admitted 12/28/13 with cellulitis of the right foot. The Nurses wound assessment notes from 12/28/14 thru 12/31/14 stated "no wound noted." The nurses wound assessment note dated 12/31/13 at 12:15 PM stated right foot wound was drained and dressing applied. On 1/2/14 the wound care nurse (E5) evaluated the right foot wound and documented the wound type was a diabetic ulcer, had moderate amount of purulent exudate, peripheral skin temperature as hot and ordered dressing changes daily. The Patient Care Plan Report stated the "Impaired Skin Integrity" care plan was not initiated until 1/7/14, seven days after the right foot wound developed.

5. During an interview at 12:30 on 1/14/14 with a registered nurse (E11) who had provided care throughout Pt #4's admission, it was acknowledged that the right foot became increasingly edematous and was weeping which required frequent dressing changes to absorb the drainage. Then a "few days" after admission an open wound developed requiring daily dressing changes. E11 stated an impaired skin integrity careplan should have been initiated in the Electronic Medical Record under the "Patient Care Plan Report" upon admission or at least upon the development of the open wound and was not.

6. Pt #7 was admitted to the hospital on 12/7/13 at 7:00 AM with the diagnosis chronic obstructive pulmonary disease (COPD). The medical record was reviewed on 1/14/14 at 3:00 PM with the Registered Nurse (RN) (E6). On 12/7/13 at 8:11 AM, ICU nursing documentation stated "Record Skin Lesions.... Pt has generalized skin tears, dry skin, and bruising. Bilateral lower legs are erythematous." On 12/7/13 at 4:50 PM, ICU nursing documentation stated "... Mepilex border placed on left buttock due to draining blood, gauze placed in groin folds... physician notified" On 12/10/13 at 10:59 AM, Wound Ostomy Nurse (WON) documentation stated "Both buttocks denuded..." It further stated the presence of a second wound skin tear on the left groin with a dressing selection of Mepilex Border and a dressing selection note of "calazime barrier cream". On 12/10/13 at 11:14 AM, WON documentation stated the presence of third wound on the left posterior thigh with no dressing selection noted and the presence of skin breakdown in folds of abdomen with dressing selection of Mepilex Border foam to the right and left locations, as well at Miconazole powder. There was no nursing care plan for impaired skin integrity initiated for Pt #7 until 12/9/13.

7. Pt #8 presented to the ED on 12/17/13 at 8:41 AM with the CC "cut foot on broken glass" and was admitted to the hospital for observation with wounds and was discharged home with Home Health on 12/20/13 with ongoing wound care needs. The medical record of Pt #8 was reviewed on 1/15/14 with E6. On 12/17/13, the nursing care plan for Pt #8 was initiated; however, impaired skin integrity was not included. As of 12/20/13, when Pt #8 was discharged, the care plan failed to include nursing diagnoses related to impaired skin integrity, nursing interventions, and/or wound care required for Pt #8.

8. Pt #9 was a direct admit from the physician office to the hospital on 12/17/13 with the diagnoses gangrene right foot and cellulitits and required wound care. On 12/20/13, Pt #9 underwent a right below the knee amputation. The medical record of Pt #9 was reviewed on 1/15/14 with E6. On 12/18/13 at 12:04 PM, there was a physician order for daily wound care to the right 1st and 2nd toes using Melgisorb and bulky dressing. On 12/23/13 at 9:25 AM, there was a physician order for daily dressing change using 4x4 and kerlix. On 12/17/13, the nursing care plan for Pt #9 was initiated; however, it failed to include any nursing diagnosis or interventions related to wound care, revisions related to surgical interventions and changes in nursing care wound needs postoperatively.

9. An interview was conducted with E6 on 1/15/14 at 3:00 PM. E6 reviewed the medical records of Pts #7, #8, and #9 and confirmed care plans failed to either be initiated, including wound care nursing diagnoses and interventions, and/or be updated with changes to wound care diagnoses and interventions.

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Based on 2 of 9 (Pt #3, #7) record reviews and staff interview, it was determined wound care was provided without a physician order. Findings include:

1. The policy titled "Skin Breakdown Prevention and Identification" (revised 3/16/13) was reviewed 1/15/14. It stated "Procedure: ...Implement wound care orders for patients with pressure ulcers...Implement wound care protocol...Record wound care protocol...collaborate with attending physician regarding continuous management..."

2.A record review for Pt #3 was conducted 1/15/14. Pt #3 was directly admitted to the medical surgical unit from a Nursing Home for evaluation and treatment of a stage 4 pressure ulcer on 1/11/14. Physician orders upon admission on 1/11/14 stated to consult the wound care nurse although no wound care was ordered until 1/14/14. Nursing wound assessments stated dressing changes were conducted 1/12/14 at 5:00 AM and 2:06 PM, 1/13/14 at 00:00, 12:25 PM and 4:03 PM, 1/14/14 at 2:09 PM and 11:10 AM.

3. During an interview at 3:40 PM on 1/15/14 with a registered nurse (E10) who had provided care for Pt #3 reviewed the physician orders and wound assessment documentation and confirmed that an order for wound care was not entered until 1/14/14. E10 stated the wound assessment documentation did not state what type of dressing change was performed on 1/12, 1/13 or 1/14 prior to obtaining the wound care orders on 1/14/14 at 8: 31 PM. E10 stated that usually the nurses assess the wound/s during the admission assessment, inquire with the patient, caregiver, home health agency, nursing home or wound care clinic what type of dressing changes were being conducted prior to admission and that dressing is continued until the wound care nurse assesses the wound, determines the appropriate wound care protocol and enters the orders into CPOE (Computerized Physician Order Entry). E10 demonstrated in the Electronic Medical Record how the nurse can enter a wound assessment and choose an approved wound care protocol for dressing changes into the CPOE. E10 stated the nurses usually just "dress the wound with whatever the patient had prior to admission and let the wound care nurse enter the protocol."

4. During an interview at 4:00 PM on 1/15/14 with the wound care nurse ( E5), it was stated Pt #3 was assessed by E5 on 1/13/14. E5 stated upon inquiring with the RN providing care for Pt #3 on 1/13/14 what type of dressing change had been performed since admission, the RN stated "Iodoform gauze packing..." E5 stated that was appropriate but did not enter an order or initiate a protocol. The RN providing care for Pt #3 on 1/14/14 entered an order for "dressing changes every shift..iodoform gauze packing..." and post dated the order 1/13/14 00:00 to reflect the verbal approval by E5 of the protocol.

5. Pt #7 was admitted to the hospital on 12/7/13 at 7:00 AM with the diagnosis chronic obstructive pulmonary disease (COPD) and had 2nd degree burn right thigh, 1st degree burn left thigh, and multiple small cuts on bilateral feet. The medical record of Pt #7 was reviewed on 1/14/14 at 3:00 PM with the Registered Nurse (RN) (E6). On 12/7/13 at 4:50 PM, nursing documentation stated "Mepilex border placed on left buttock due to draining blood... Physician notified". There was no physician order for dressing changes. There was no wound care protocol initiated by the nurse and/or signed by the physician.

6. During an interview at 4:15 PM on 1/15/14 with the Nurse Manager (E8), it was stated he/she was unaware the nurses were not initiating the approved wound care protocols and were providing wound care without physician orders. E8 stated there was no policy regarding implementing wound care protocols but education had been provided and confirmed it was an unacceptable practice.

Based on document/ record review and interview, it was determined for 1 of 10 (Pts #7) patients, discharge wound care orders were not written for ongoing wound care needs.
Findings include:

1. Pt #7 was admitted to the Intensive Care Unit (ICU) on 12/7/13 at 7:00 AM with the diagnosis chronic obstructive pulmonary disease (COPD). The medical record was reviewed on 1/14/14 at 3:00 PM with the Registered Nurse (RN) (E6). On 12/7/13 at 8:11 AM, ICU nursing documentation stated "Record Skin Lesions.... Pt has generalized skin tears, dry skin, and bruising. Bilateral lower legs are erythematous." On 12/10/13 at 10:50 AM, ICU nursing documentation stated "Wound Assessment... Mepilex Border dressing applied to denuded left upper leg..." On 12/10/13 at 10:59 AM, Wound Ostomy Nurse (WON) documentation stated "Both buttocks denuded..." There was no documentation as to the presence of a dressing on the buttock or when the buttock dressing was removed. It further stated the presence of a second wound skin tear on the left groin with a dressing selection of Mepilex Border and a dressing selection note of "calazime barrier cream". On 12/10/13 at 11:14 AM, WON documentation stated the presence of third wound on the left posterior thigh with no dressing selection noted and the presence of skin breakdown in folds of abdomen with dressing selection of Mepilex Border foam to the right and left locations, as well at Miconazole powder. On 12/10/13 at 3:39 PM, there was a physician order to discharge Pt #7 back to the long term acute care hospital. As of 1/15/14 at 3:00 PM, the hospital was unable to produce any discharge orders for Pt #7 concerning diet, activity, medications, wound/skin care, etc. or any transfer information that would have been sent with the patient for continuity of care.

2. Pt #8 presented to the ED on 12/17/13 at 8:41 AM with the CC "cut foot on broken glass" and was admitted to the hospital for observation with wounds and was discharged home with Home Health on 12/20/13. The medical record of Pt #8 was reviewed on 1/15/14 with E6. On 12/17/13 at 2:16 PM, there were physician orders for wound care nurse consult with subsequent orders for cleansing and dressing of burns on the right and left legs of Pt #8 daily. As of 12/20/13, nursing skin/wound documentation stated Pt #8 continued to have wounds that required dressing changes daily. On 12/20/13, the physician discharge orders failed to include orders for ongoing wound care for Pt #8.

3. Pt #9 was a direct admit from the physician office to the hospital on 12/17/13 with the diagnoses gangrene right foot and cellulitits requiring wound care. The medical record of Pt #9 was reviewed on 1/15/14 with E6. On 12/20/13, Pt #9 underwent a right below the knee amputation. On 12/23/13 at 9:25 AM, there was a physician order for daily dressing change using 4x4 and kerlix. On 12/27/13, Pt #9 was transferred to an outlying rehabilitation unit for ongoing care. There was no discharge order for ongoing wound care. As of 1/15/14 at 3:00 PM, the hospital was unable to produce any transfer information that would have been sent with the patient for continuity of care.

4. An interview was conducted with E6 on 1/15/14 at 3:00 PM. E6 reviewed the medical records of Pts #7, #8, and #9. E6 stated the discharge orders were expected to include orders for ongoing wound care and confirmed that Pts #7, #8, and #9 s' discharge orders did not include this and should have. E6 further stated that a transfer sheet with all pertinent information such as wound care is to be sent with all patients who go to a nursing home, another hospital, etc. E6 confirmed that Pts #7 and #9 did not have transfer information, inclusive of wound care sent with them for ongoing care.



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