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Based on interview, record review, review of facility policies, and a review of professional nursing standards, the Lippincott Manual Nursing Practice, Ninth Edition, and the Agency for Health Care Policy and Research Clinical Practice Guidelines utilized by the facility, the facility failed to ensure quality patient care was provided by Nursing Services for seven of ten sampled patients (Patients #1, #2, #5, #6, #7, #8, and #9). The facility failed to ensure ongoing assessments of skin and/or wounds were performed and documented for the identified patients in accordance with facility policy and protocols.

The findings include:

Review of the facility's Wound Care/Skin Integrity policy (revised 12/01/11) revealed upon admission all patients would be assessed for the risk of skin breakdown. According to the policy, wound care would be documented on the Wound Care Flow Chart. The review further revealed patients would be reassessed periodically and the assessments would be documented on the shift assessment flowchart.

Review of the Lippincott Manual Nursing Practice, Ninth Edition, which the facility utilized for their professional standards of practice, revealed nursing staff should assess the skin status of older adult patients frequently for the development of pressure ulcers.

Review of the Agency for Health Care Policy and Research Clinical Practice Guidelines on "How to Guide: Prevent Pressure Ulcers," which the facility also utilized for their professional standards of practice, revealed recommendations of an initial pressure ulcer risk assessment on admission and reassessments periodically based on the patient's condition.

Interview conducted on 01/24/12, at 3:35 PM, with the Quality Assurance (QA) Manager confirmed the facility utilized the Lippincott Manual and the Agency for Health Care Policy and Research Clinical Practice Guidelines for their professional standards. The QA Manager revealed the facility's protocol for skin/wound assessments was for all patients to be assessed upon admission for the risk of development of pressure ulcers utilizing the "Braden" scale. (The Braden scale is a tool used to assess a patient's risk for developing a pressure ulcer by examining six criteria: 1- Sensory Perception, 2- Moisture, 3- Activity, 4- Mobility, 5- Nutrition, and 6- Friction/Shear.) The interview revealed the facility's assessments were electronic and after the admission assessment the computer automatically calculated the patient's Braden scale which then triggered routine physician's orders related to skin care. The QA Manager stated upon a patient's admission the nurse was responsible to assess all wounds with detailed description, measurements, and pictures on a wound care photo sheet. The interview revealed the nurses were responsible to conduct a head to toe skin assessment every shift and as needed. According to the QA Manager, the nurses were also required to conduct a wound assessment every shift or when wound care was performed. The interview revealed a wound assessment should include detailed descriptions of the wound bed, edges, drainage, size, and odor, and the assessments should be documented on the wound care flow chart.

Based on documentation, Patient #1 was admitted to the facility on 12/31/11. The review revealed Patient #1's diagnoses included Diabetes, Peripheral Vascular Disease, Hypertension, history of Myocardial Infarction (heart attack), and a history of an Embolus (blood clot) to the left lower extremity which resulted in an Above the Knee Amputation (AKA) of the patient's left leg.

Review of Patient #1's admission assessment dated 12/31/11, revealed the patient had a Stage III pressure ulcer (Stage III pressure ulcer is full thickness tissue loss, where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) to the buttock that was dark purple in color and had black/brown eschar (eschar is a slough or piece of dead tissue that is cast off from the surface of the skin). The patient was also assessed to have a surgical incision from a recent left AKA with staples intact. However, there was no documentation of the measurements of the wounds on the day of the patient's admission. Review of Patient #1's admission physician's orders revealed the patient was to be turned every two hours from side to side, nursing staff was to clean the patient's residual limb on the left side with water twice a day, and clean the patient's pressure ulcer to the buttocks with Betadine and cover the ulcer with a dressing twice a day. Review of Patient #1's nurses notes and wound care flow chart revealed Registered Nurse (RN) #3, Licensed Practical Nurse (LPN) #1, LPN #2, LPN #3, and LPN #4 provided care to the patient during his/her hospitalization but failed to document the actual location of the patient's wounds, a description of the wounds that included size, description of the wound bed, edges of the wound, or drainage and odor (if any) from the wound. Based on staff documentation, the location of the wounds to the patient's buttocks varied from one side of the buttock to the other and/or on both sides of the buttocks. It could not be determined based on a review of documentation if the variances in location of the wounds were due to an error in documentation or a change in the patient's condition. Further review revealed on 01/10/12 (10 days after admission), a heel protector was placed to the patient's right foot; however, facility staff failed to document the status of the patient's right heel throughout the patient's 19-day admission to the facility. A review of nurse's notes and a wound care flow chart dated 01/19/12, revealed RN #3 had documented the patient had eschar to the buttock area bilaterally. The patient was discharged from the facility on 01/19/12, and based on a review of the physician's discharge orders Patient #1 was to return to the facility on 01/20/12, for debridement of the wound to the coccyx area.

Interview conducted on 01/24/12, at 2:35 PM, with RN #1 revealed Patient #1 had bilateral wounds to the buttock area upon admission to the facility but the RN had failed to obtain and document measurements of the wounds. RN #1 confirmed the nurses were aware of the facility's protocol for skin/wound assessments.

Interview conducted on 01/24/12, at 3:05 PM, with LPN #1 confirmed she provided wound care and skin assessments for Patient #1 on 01/07/12, 01/08/12, 01/10/12, 01/11/12, and 01/17/12. LPN #1 stated she failed to document a description of the wounds and skin as per protocol. LPN #1 acknowledged Patient #1's scrotum was red and swollen and the patient's right heel was red. However, the LPN failed to document the status of the patient's scrotum, the heel, or that the physician had been made aware of the status of the resident's skin. LPN #1 confirmed the nurses were aware of the facility's protocol for skin/wound assessments.

Interview conducted on 01/24/12, at 4:10 PM, with LPN #2 confirmed she provided wound care and had conducted skin assessments for Patient #1 on 01/03/12, 01/05/12, 01/07/12, 01/08/12, and 01/10/12. LPN #2 also confirmed she failed to document a description of the patient's wounds and skin in accordance with facility policy. LPN #2 stated Patient #1's scrotum was red and swollen and nurses performed treatment to the patient's heel or toe. However, the LPN failed to document the status of the patient's scrotum or heel or that the physician was aware of the status of the areas. LPN #2 confirmed the nurses were aware of the facility's protocol for skin/wound assessments.

Interview conducted on 01/24/12 at 5:30 PM with LPN #3 revealed she had also provided wound care and conducted skin assessments of Patient #1 on 12/31/11, 01/02/12, 01/03/12, 01/04/12, 01/09/12, 01/13/12, and 01/18/12. However, the LPN acknowledged she had failed to document a description of the wounds and skin in accordance with the facility's policy. LPN #3 confirmed the nurses were aware of the facility's protocol for skin/wound assessments.

Interview conducted on 01/24/12, at 7:05 PM, with LPN #4 confirmed she provided wound care and skin assessments on Patient #1 on 01/16/12 and 01/18/12, and failed to document a description of the wounds and skin as per protocol. LPN #4 stated Patient #1's scrotum was red and swollen. However, there was no documentation of the patient's scrotum or that the nurse had made the physician aware of the reddened areas. LPN #4 confirmed the nurses were aware of the facility's protocol for skin/wound assessments.

Interview conducted on 01/24/12, at 6:55 PM, with RN #3 confirmed she provided wound care and had conducted an assessment of Patient #1's skin on 01/19/12, prior to the patient's discharge from the facility. The RN stated she failed to document a description of the wounds and skin in accordance with the facility's policies and protocols. RN #3 stated in addition to the pressure areas on the patient's buttocks, Patient #1's scrotum was red and swollen and the patient's right heel was red. However, there was no documentation of the patient's scrotum or heel or that the physician was aware these areas were red. RN #3 confirmed the nurses were aware of the facility's protocol for skin/wound assessments.

Upon Patient #1's discharge from the facility on 01/19/12, the patient was readmitted to a long term care facility. A review of documentation in Patient #1's medical record from the long term care facility revealed the long term care facility staff conducted a skin assessment on 01/19/12, and noted Patient #1 had a reddened Stage II pressure sore (Stage II pressure ulcer is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the scrotum which measured 0.7 centimeters (cm) by 0.7 cm by 0.2 cm. The long term care staff documented the patient also had a "pink" Stage II pressure sore to the scrotum that measured 1.0 cm by 1.6 cm by 0.2 cm. A dark pink Stage II pressure area was documented to be located on the patient's right buttock and measured 1.0 cm by 1.0 cm by 0.0. An unstageable eschar (unstageable is full thickness tissue loss in which the base of the ulcer is covered by slough--yellow, tan, gray, green or brown--and/or eschar--tan, brown, or black--in the wound bed) area was noted to be located to the patient's left buttock which was described as black and measured 11.0 cm by 9.0 cm by 0.0 cm. The long term care staff documented a red "suspected deep tissue injury" (Suspected Deep Tissue Injury is purple/maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure/shear) was noted to the patient's right outer heel and measured 3.0 cm by 3.5 cm by 0.0 cm. In addition, documentation in the long term care record revealed Patient #1 had an area to the right buttock with black eschar that measured 9.0 cm by 4.5 cm by 0.0 cm.

Additional medical records from the facility were selected for review. A review of the medical records of Patients #2, #5, #6, #7, #8, and #9 revealed the patients were admitted to the facility with pressure ulcers. The reviews revealed nursing staff failed to assess and document the details of the patient's wounds/pressure sores to include the wound's appearance, size, location, drainage, or odor in accordance with facility policies and procedures. Due to a lack of documentation, it could not be determined if the patients' pressure areas improved or declined during their admission to the facility.

Interview conducted on 01/24/12, at 3:35 PM, with the Chief Nursing Officer and the QA Manager revealed nursing staff had previously received training on the facility's policies and protocols for the assessment and documentation of the status of each patient's skin. The interview revealed no one monitored/ensured nursing staff was conducting skin/wound assessments and documenting the findings according to facility protocols.