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Based on staff interview and review of medical records, it was determined the CAH failed to ensure nursing services met the needs of 4 of 11 inpatients (#12, #14, #15, and #20) whose records were reviewed. This resulted in patients experiencing skin breakdown and constipation. Findings include:

The document "Pressure Ulcer Prevention Points," published by the National Pressure Ulcer Advisory Panel in 2007, recommended "Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care." The CAH did not ensure patients' medical records contained evidence this standard of care had been met. Additionally, the CAH did not ensure patients' received the nursing care necessary to prevent and address constipation. Examples include:

1. Patient #15's medical record documented a 93 year old male who was admitted to the CAH on 11/07/10. He was changed to swing bed status on 11/13/10. He was discharged from the hospital on 11/24/10. His discharge diagnosis was urosepsis.

Patient #15's "Integumentary [skin] Assessment," dated 11/07/10 at 2:30 AM, stated his skin was intact. His skin proceeded to break down. A nursing "Assessment Forms," dated 11/10/10 at 8:22 PM, stated he had three stage II pressure ulcers on his coccyx. A physician progress note, dated 11/12/10, stated Patient #15 had a "Sacral decubitus ulcer." The nursing "Assessment Forms," dated 11/21/10 at 11:17 AM, stated he had a three stage III pressure ulcer on his sacrum and coccyx. The nursing "Assessment Forms," dated 11/23/10 at 12:17 AM, stated he had "pressure blisters" on both heels. A NCP for the prevention of skin breakdown and pressure ulcers was not documented in his medical record.

Position changes were not documented consistently as in the following examples:

-- 11/11/10 from 12:12 AM to 5:02 AM, 4 hours and 50 minutes
-- 11/11/10 from 5:02 AM to 12:14 PM, 7 hours and 12 minutes
-- 11/12/10 from 5:21 AM to 9:48 AM, 4 hours and 27 minutes
-- 11/12/10 from 2:16 PM to 6:37 PM, 4 hours and 21 minutes
-- 11/13/10 from 12:03 AM to 11:09 AM, 11 hours and 6 minutes
-- 11/13/10 from 11:35 AM to 11:54 PM, 12 hours and 19 minutes

In addition, nursing staff failed to take action to regulate Patient #15's bowels. Nursing "Progress Notes" documented Patient #15 received a suppository on 11/14/10 at 7:17 PM. Results were not documented. He also received a suppository on 11/15/10 at 8:07 AM without results. Nursing "Progress Notes" documented Patient #15 was incontinent of stool at 10:30 AM on 11/15/10, but the amount and quality was not described. On 11/16/10 at 8:22 AM, the nurse documented he complained of pressure in his rectum and at 3:22 PM, he was incontinent of a small amount of stool. No bowel movements were documented on 11/17/10. On 11/18/10 at 4:25 PM, nurses documented Patient #15 complained of rectal pain. At 9:46 PM, he received an oil retention enema. On 11/19/10 at 8:20 AM, the nurse documented Patient #15 was "leaking watery stool." At 10:33 AM he was manually disimpacted of stool. A bowel movement was not documented on 11/20/10. Two small bowel movements were documented on 11/21/10. Nurses documented Patient #15 complained of rectal pain at 11:30 AM on 11/22/10 and then leaked five loose stools between 5:24 PM and 10:20 PM. No stools were documented on 11/23/10 and 11/24/10. Consistent approaches to bowel care were not documented nor were measures such as checking him manually to determine if he was impacted. A NCP to assist with the regulation of Patient #15's bowels was not documented in his medical record.

Patient #15's medical record was reviewed with the Clinical Analyst, who was also an RN, beginning at 3:05 PM on 11/29/11. She confirmed the documentation and stated she could not find documentation of an organized approach to treating Patient #15's skin and bowel problems.

Nursing staff did not adopt consistent approaches to prevent skin breakdown and constipation.

2. Patient #12's medical record documented an 88 year old female who was admitted to the CAH on 11/21/11 for pneumonia. Patient #12 was placed on comfort care measures on 11/22/11 and curative measures were discontinued. She passed away at the hospital on 11/28/11.

Patient #12's "Adult Admission Assessment," dated 11/21/11 at 12:50 PM, stated she had a history of pressure sores on her lower back. She had a "Skin Integrity Risk Score" of 12, indicating a high risk of skin breakdown. A nursing "Assessment Forms," dated 11/21/11 at 12:50 PM, described her skin as "Not intact." Bruises were noted on her abdomen, left foot, left hand, and right arm. Also, the skin beneath her breasts was described as "excoriated with open areas..." A nursing "Progress Notes," dated 11/26/11 at 11:55 PM, stated Patient #12 had a 3.5 cm by 4.5 cm "red and purple spot" on her left heel. An "Allevyn dressing" was applied to the heel at that time. A nursing "Assessment Forms," dated 11/26/11 at 9:11 PM, stated Patient #12 had a "Wound due to pressure" on her right buttock but did not describe the wound. A nursing "Assessment Forms," dated 11/27/11 at 9:53 PM, stated Patient #12 had "Wound[s] due to pressure" on her right buttock and right heel but it did not describe the wounds. A NCP for the prevention of skin breakdown and pressure ulcers was not documented in her medical record.

Position changes were not documented consistently as in the following examples:

-- 11/21/11 from 5:56 AM to 11:06 AM, 5 hours and 10 minutes
-- 11/21/11 from 11:06 AM to 10:07 PM, 11 hours and 1 minute
-- 11/23/11 from 2:00 PM to 5:41 PM, 3 hours and 41 minutes
-- 11/24/11 from 4:12 AM to 6:50 PM, 4 hours and 38 minutes

In addition, a bowel movement was not documented for Patient #12 during her entire seven day stay. Checks to determine if Patient #12 needed bowel care were not documented. A NCP to assist with the regulation of Patient #12's bowels was not documented in her medical record.

Patient #12's medical record was reviewed with the Clinical Analyst beginning at 9:25 AM on 11/30/11. She confirmed the documentation and agreed that systematic care for the prevention of skin breakdown and pressure ulcers was not documented in her medical record. She also stated actions to ensure Patient #12 was not constipated were not documented.

Nursing staff did not adopt consistent approaches to prevent skin breakdown and constipation.

3. Patient #20's medical record documented a 77 year old male who was admitted to the CAH on 11/21/11 for congestive heart failure and dehydration. He was transferred to an acute care hospital on 11/29/11.

Patient #20's "Assessment Forms," dated 11/21/11 at 9:06 PM, stated he had a 0.50 cm by 0.50 cm "Wound due to pressure" on his coccyx. A nursing "Assessment Forms," dated 11/26/11 at 8:50 PM, stated he had pressure wounds on his right buttock and his coccyx. The wound on his coccyx measured 2 cm by 1 cm. A nursing "Assessment Forms," dated 11/28/11 at 11:13 AM, stated he had stage II pressure ulcers on his coccyx and buttocks. A NCP for the prevention of skin breakdown and pressure ulcers was not documented in his medical record.

Position changes were not documented consistently as in the following examples:

-- 11/22/11 from 7:03 AM to 3:22 PM, 8 hours and 19 minutes
-- 11/22/11 from 6:09 PM to 9:00 PM, 2 hours and 51 minutes
-- 11/24/11 from 6:44 AM to 2:30 PM, 7 hours and 46 minutes
-- 11/24/11 from 2:16 PM to 6:37 PM, 4 hours and 21 minutes
-- 11/25/11 from 6:07 AM to 10:00 AM, 3 hours and 53 minutes
-- 11/26/11 from 2:47 PM to 8:20 PM, 5 hours and 37 minutes

In addition, nursing staff failed to take action to regulate Patient #20's bowels. Nursing "Progress Notes" did not document if Patient #20 had had a bowel movement for 5 days, between 11/21/11 and 11/26/11, when he complained of constipation. No nursing actions to promote a bowel movement were documented during that time. A NCP to assist with the regulation of Patient #20's bowels was not documented in his medical record.

Patient #20's medical record was reviewed with the Clinical Analyst beginning at 9:25 AM on 11/30/11. She confirmed the documentation and agreed consistent actions to prevent skin breakdown and constipation were not documented.

Nursing staff did not adopt consistent approaches to prevent skin breakdown and constipation.



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4. Patient #14 was a 90 year old female admitted to the CAH on 8/15/11. She was discharged to swing bed status on 8/19/11 and then readmitted to inpatient status on 8/28/11 for unresponsiveness and a UTI.

An "Adult Admission Assessment," dated 8/15/11 at 6:56 PM, documented bilateral lower extremities having bruising, dryness, and flaking. The "Skin Integrity Risk Score" at that time was 16 of 23, which indicated a risk of developing a pressure ulcer. A NCP for the prevention of skin breakdown was not documented in her medical record.

Patient #14 was readmitted to the inpatient unit on 8/28/11. An "Adult Admission Assessment," dated 8/28/11 at 5:30 PM, documented "erythema" (redness) on the coccyx and bilateral lower extremities having bruising, dryness, and flaking. The "Skin Integrity Risk Score" at that time was 15 of 23, which indicated a risk of developing a pressure ulcer. A NCP for the prevention of skin breakdown was not documented in her medical record.

An "Adult Ongoing Assessment," dated 9/05/11 at 5:44 AM, documented a lesion on the left gluteal fold that was 2 millimeters in diameters with a red center and no discharge, which the nurse covered with a padded foam dressing. Patient #14 was discharged home later that day.

Position changes were not documented consistently as in the following examples:

-- 8/15/11 from 8:33 PM to 8/16/11 at 9:27 AM, 12 hours and 54 minutes
-- 8/18/11 from 4:06 AM to 1:20 PM, 9 hours and 14 minutes
-- 8/22/11 from 2:22 PM to 8/23/11 at 5:32 AM, 15 hours and 10 minutes
-- 8/28/11 from 1:12 AM to 11:33 AM, 10 hours and 21 minutes
-- 8/29/11 from 1:33 AM to 11:02 AM, 9 hours and 29 minutes
-- 8/29/11 from 10:44 PM to 8/30/11 at 8:00 AM, 9 hours and 16 minutes
-- 8/31/11 from 9:39 PM to 9/01/11 at 8:17 AM, 10 hours and 38 minutes
-- 9/01/11 from 2:54 PM to 9/02/11 at 12:36 AM, 9 hours and 42 minutes
-- 9/02/11 from 8:38 PM to 9/03/11 at 7:23 AM, 10 hours and 45 minutes
-- 9/03/11 from 7:46 PM to 9/04/11 at 5:28 AM, 9 hours and 32 minutes

Patient #14's medical record was reviewed with the Clinical Analyst, who was also an RN, at 11:30 AM on 11/29/11. She confirmed the documentation and stated she agreed consistent actions to prevent skin breakdown were not documented.

Nursing staff did not adopt consistent approaches to prevent skin breakdown.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure NCPs were developed and kept current for 5 of 11 inpatients (#12, #14, #15, #20, and #21) whose records were reviewed. This resulted in a lack of direction to nursing staff caring for patients. Findings include:

1. Patient #15's medical record documented a 93 year old male who was admitted to the CAH on 11/07/10. He was changed to swing bed status on 11/13/10. He was discharged from the hospital on 11/24/10. His discharge diagnosis was urosepsis.

Patient #15's "Integumentary [skin] Assessment," dated 11/07/10 at 2:30 AM, stated his skin was intact. His skin proceeded to break down. A nursing "Assessment Forms," dated 11/10/10 at 8:22 PM, stated he had three stage II pressure ulcers on his coccyx. A physician progress note, dated 11/12/10, stated Patient #15 had a "Sacral decubitus ulcer." The nursing "Assessment Forms," dated 11/21/10 at 11:17 AM, stated he had a three stage III pressure ulcer on his sacrum and coccyx. The nursing "Assessment Forms," dated 11/23/10 at 12:17 AM, stated he had "pressure blisters" on both heels.

Patient #15's nursing "Progress Notes," dated 11/13/10 at 11:05 PM, stated he was leaking stool. Nursing "Progress Notes," dated 11/14/10 at 7:17 PM and 11/15/10 at 8:07 AM, stated he received suppositories without results. Nursing "Progress Notes," dated 11/16/10 at 3:22 PM stated he was incontinent of a small amount of stool. Nursing "Progress Notes," dated 11/19/10 at 10:33 AM, stated Patient #15 had to have stool removed manually.

Patient #15's medical record documented a nursing "Plan of Care" that contained two problems: falls and "Impaired Skin Integrity." The falls plan was not initiated until 11/15/10. The skin integrity plan was not initiated until 11/24/10; fourteen days after he developed pressure sores. A NCP was not documented for Patient #15's urinary tract infection or his bowel problems.

Patient #15's medical record was reviewed with the Clinical Analyst, who was also an RN, beginning at 3:05 PM on 11/29/11. She confirmed the documentation and agreed the NCP did not address pressure sores, bowel management, and/or urinary problems.

The CAH did not develop and keep current a NCP for Patient #15.

2. Patient #12's medical record documented an 88 year old female who was admitted to the CAH on 11/21/11 for pneumonia. Patient #12 was placed on comfort care measures on 11/22/11 and curative measures were discontinued. She passed away at the hospital on 11/28/11.

Patient #12's admission nursing assessment, dated 11/21/11 at 12:50 PM, stated she had a history of pressure sores on her lower back. A nursing "Progress Notes," dated 11/26/11 at 11:55 PM, stated Patient #12 had a 3.5 cm by 4.5 cm "red and purple spot" on her left heel. An "Allevyn dressing" was applied to the heel at that time.

A bowel movement was not documented for Patient #12 during her seven day stay.

Patient #12's medical record documented a nursing "Plan of Care" that contained one problem: impaired gas exchange. Skin break down and bowel care were not included in the NCP.

Patient #12's medical record was reviewed with the Clinical Analyst beginning at 9:25 AM on 11/30/11. She confirmed the documentation and agreed the NCP did not address pressure sores or bowel management.

The CAH did not develop and keep current a NCP for Patient #12.

3. Patient #20's medical record documented a 77 year old male who was admitted to the CAH on 11/21/11 for congestive heart failure and dehydration. He was transferred to an acute care hospital on 11/29/11.

Patient #20's nursing "Progress Notes," dated 11/28/11 at 11:48 AM, stated he had "Stage II pressure ulcers" on his right upper gluteal area and coccyx.

Patient #20's nursing "Progress Notes," dated 11/23/11 at 12:59 AM, stated he was confused and upset. The note stated he was cursing and trying to hit staff. The note stated he refused to wear his oxygen and had pulled his intravenous line out. The note also stated Patient #20 had trouble "taking anything by mouth" on the previous day.

The antipsychotic medications Haldol and Risperidone were ordered on 11/24/11 at 8:38 PM and on 11/25/11 at 9:00 PM, respectively, to manage behaviors.

Patient #20's medical record documented a nursing "Plan of Care" that contained one problem: fall risk. Pressure sores and behavioral issues were not addressed on the NCP.

Patient #20's medical record was reviewed with the Clinical Analyst beginning at 9:25 AM on 11/30/11. She confirmed the documentation and agreed the NCP did not address pressure sores or behaviors.

The CAH did not develop and keep current a NCP for Patient #20.



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4. Patient #14 was a 90 year old female admitted to the CAH on 8/15/11. She was discharged to swing bed status on 8/19/11 and then readmitted to inpatient status on 8/28/11 for unresponsiveness and a UTI.

An "Adult Admission Assessment," dated 8/15/11 at 6:56 PM, documented bilateral lower extremities having bruising, dryness, and flaking. The "Skin Integrity Risk Score" at that time was 16 of 23, which indicated a risk of developing a pressure ulcer. A NCP for the prevention of skin breakdown was not documented in her medical record.

Patient #14's medical record documented a nursing "Plan of Care," initiated 8/15/11, that contained two problems: "VTE Quality Measures" (Venous ThromboEmbolism) and risk for falls. The NCP did not contain the risk for skin impairment as determined by the "Skin Integrity Risk Score" of 16.

Patient #14 was readmitted to the inpatient unit on 8/28/11. An "Adult Admission Assessment," dated 8/28/11 at 5:30 PM, documented "erythema" (redness) on the coccyx and bilateral lower extremities having bruising, dryness, and flaking. The "Skin Integrity Risk Score" at that time was 15 of 23, which indicated a risk of developing a pressure ulcer. A NCP for the prevention of skin breakdown was not documented in her medical record.

Patient #14's medical record documented a nursing "Plan of Care," initiated 8/28/11, that contained two problems: "VTE Quality Measures" (Venous ThromboEmbolism) and risk for aspiration (swallowing substances into the lungs). The NCP did not contain the risk for skin impairment as determined by the "Skin Integrity Risk Score" of 15.

An "Adult Ongoing Assessment," dated 9/05/11 at 5:44 AM, documented a lesion on the left gluteal fold that was 2 millimeters in diameters with a red center and no discharge, which the nurse covered with a padded foam dressing. Patient #14 was discharged home later that day.

Patient #14's medical record was reviewed with the Clinical Analyst, who was also an RN, at 11:30 AM on 11/29/11. She confirmed the documentation and stated she agreed the NCP did not address the risk for skin breakdown.

The CAH did not develop and keep current an NCP for Patient #14.

5. Patient #21 was an 87 year old female admitted to the CAH on 11/28/11. Her "Adult Admission Assessment," dated 11/28/11 at 8:28 PM, did not include a "Skin Integrity Risk Score," but did include documentation of risk factors affecting skin condition. The risk factors included that Patient #21 was bedfast, had moist skin, had a problem related to friction and shear injuries, and had "probably inadequate" nutrition. Further, Patient #21 had a documented ulcer on her coccyx.

Patient #21's nursing "Plan of Care," initiated 11/29/11 at 2:37 AM, documented one problem: risk for aspiration. The NCP did not contain the impaired skin, or risk of further skin breakdown, based on the admission assessment.

Patient #21's medical record was reviewed with the Clinical Analyst, who was also an RN, at 1:00 PM on 11/30/11. She confirmed the documentation and stated she agreed the NCP did not address the actually or risk for skin breakdown.

The CAH did not develop and keep current a NCP for Patient #21.

6. The policy "CARE PLANS," dated 7/19/11, stated a care plan would be initiated within 24 hours of admission. The policy stated care plans would be based on individual needs. The policy did not include a procedure that provided guidance to staff as to how these plans would be developed and documented.

The Chief Nursing Officer was interviewed on 11/30/11 beginning at 1:30 PM. She stated the electronic medical record interfered with and prevented nurses from developing complete care plans. She confirmed a procedure providing direction to staff within the frame work of the CAH's electronic medical record had not been developed.

The CAH did not develop complete NCPs.