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Based on medical record review, staff interview, and review of policy and procedures it was determined the facility failed ensure the nursing staff:

1. accurately assessed and identified the condition of the patient's skin or presence of pressure ulcers or wounds upon admission or acquired while at the facility for six of thirteen sampled patients (#1, #5, #6, #8, #9, #10). Refer to A0395.

2. failed to ensure nursing interventions for turning and repositioning were completed as initiated in the nursing plan of care for one (#10) of thirteen sampled patients. Refer to A0396.

3. failed to prevent pressure ulcers from worsening or developing six (#1, #5, #6, #8, #9, #10) of thirteen sampled patients. Refer to A0395 and A0396.

4. failed to ensure nursing staff initiated interventions for patient identified wounds for three (#6, #8, #9) of thirteen patients sampled. Refer to A0396.

5. Observation and family interview revealed the nursing staff failed to provide timely request for incontinent care. Refer to A0395.

The cumulative effect of the nursing staff's failure to ensure the patient's skin was assessed, early skin breakdown identified, interventions initiated to prevent pressure ulcers from worsening or developing and to ensure nursing interventions were performed resulted in the determination that the Condition of Nursing Services is out of compliance.

Based on medical record review, review of policy and procedures, and staff interview it was determined the Registered Nurse failed to ensure the nursing staff adhered to the facility's policy for wound assessments and wound treatment for supervision and evaluation of wounds for six (#1, #5, #6, #8, #9, #10) of thirteen sampled patients. This practice does not ensure safe and effective patient care therefore placing the patient's at risk for developing or worsening of pressure ulcers.

Findings include:

Review of facility's policy and procedure "Wound Prevention" H-WC 01-001 dated 6/11 indicated to complete and document a visual and tactile assessment of the patient's skin during each shift.

1. Patient #1 was admitted on 12/02/11. Review of the nursing admission assessment completed on 12/02/11 at 9:07 p.m. revealed the patient was bed bound. The nursing assessment revealed the patient had a left below the knee amputation as well as four toes amputated on the right foot. The patient was noted to be immobile.

Review of the nursing admission assessment revealed the patient's skin on admission was intact. The Braden Scale assessment upon admission was 12, which indicated the patient was at high risk for skin breakdown.

Review of the record revealed on 12/05/11 the wound care nurse assessed the patient. Documentation revealed no skin breakdown and a recommendation for barrier cream, routine skin care and a redistribution mattress. Documentation revealed the patient was placed on the mattress on 12/05/11 and the barrier cream initiated.

Review of the nursing documentation revealed on 12/16/11, two weeks after admission, nursing assessed the patient to have a wound on the buttock crease measuring 4 x 2 x 0.1 cm (centimeters). Documentation revealed on 12/16/11 the physician was notified and a referral for the wound care nurse was placed. Review of the record revealed the wound care nurse assessed the patient on 12/21/11, five days after the referral.

Review of the facility's policy, "Initial Wound Treatment" , #H-WC 03-002, stated the Wound Care Coordinator (WCC) would evaluate the patient within 72 hours of a referral.

On 12/21/11 at 3:04 p.m. the WCC assessed the patient. Documentation revealed the patient had a hospital acquired gluteal fold ulcer measuring 10 x 3 x 0.1 cm, stage III, with full thickness skin loss involving damage or necrosis of subcutaneous tissue. Documentation revealed no additional wound interventions except the barrier cream, which was still being applied as evidenced by daily nursing documentation. Nursing failed to update the nursing plan of care and to initiate interventions for a worsening pressure ulcer.

Review of the record revealed the WCC reassessed the patient on 1/13/12 that was three weeks and two days from the previous assessment completed by the WCC.

Review of the facility's policy, "Wound Assessment and Classification", #H-WC 02-001, stated weekly assessments will be conducted by the WCC.

Review of the record revealed photographs dated 1/13/12 of the documented gluteal fold ulcer, right buttock and left buttock. Documentation by the WCC on 1/13/12 revealed a gluteal fold ulcer measuring 3.2 x 0.5 x 0 cm, stage III, hospital acquired ulcer. There was no documentation by the WCC of the right or left buttock that was photographed on 1/13/12.

Interview with the WCC on 2/22/12 at 3:30 p.m. confirmed the barrier cream was the only intervention being applied to the gluteal ulcer from 12/21/11 to 1/18/12.

On 1/23/12 at 5:26 p.m. the WCC reassessed the patient. Documentation revealed the patient had a hospital acquired ulcer to the gluteal fold measuring 2.7 x 0.7 x 0.1 cm, stage III, with full thickness skin loss involving damage or necrosis of subcutaneous tissue, with yellow, non-necrotic center and red granular edges.

On 1/25/12 the wound care physician assessed the patient's ulcer. The physician assessed the patient to have right buttock excoriation with small punctuate area on the right. On the left buttock there was complete dermal loss with good epithelization. In the gluteal cleft there was a small wound measuring approximately 18 x 5 mm (millimeters) wide, pink with good granulation at the base.

On 1/27/12 the wound care nurse assessed the patient at 1:18 p.m. Documentation revealed the gluteal fold ulcer measuring 2.7 x 0.7 x 0.1 cm, stage III, with full thickness skin loss involving damage or necrosis of subcutaneous tissue and 25% epithelialization of the wound. There was no documentation of the right or left buttock excoriation that was assessed by the wound care physician on 1/25/11.

On 2/03/12 at 11:50 a.m. the wound care nurse assessed the patient. The gluteal fold ulcer was assessed and measured and noted to be unchanged from the 1/27/11 assessment. Documentation revealed a hospital acquired left buttock ulcer measuring 6 x 8 cm, stage II, with partial thickness skin loss involving epidermis and/or dermis, denuded. There was no documentation by the wound care nurse of excoriation to the right buttock as documented by the physician on 1/25/11.

On 2/08/12 the wound care physician assessed the patient. The physician documented the patient had a stage IV pressure wound of the coccyx and would undergo debridement. Review of the operative notes revealed on 2/08/12 a stage IV pressure ulcer of the coccyx and left buttock was present and a sharp excisional debridement of the skin, subcutaneous tissue and muscle of the coccyx and left buttock was performed.

On 2/09/12 at 2:54 p.m. the wound care nurse assessed the patient. The gluteal fold ulcer was assessed and documented measurement was 5 x 3 x 1.5 cm, stage III, with full thickness skin loss and 25% epithelialization of wound covered. Documentation revealed the left buttock ulcer measured 9 x 5 x 1. 8 cm, stage III, with full thickness skin loss involving damage or necrosis of subcutaneous tissue and 25% epithelialization of wound covered. There was no documentation of the right buttock or nursing interventions to the right buttock.

On 2/13/12 at 2:02 p.m. the WCC assessed the patient. Documentation revealed the gluteal fold ulcer measured 5 x 3 x 1.4 cm and was a stage III. The left buttock was assessed as 9 x 4.8 x 1.6 cm and was a stage II. The patient was discharged from the facility on 2/13/12.

2. Patient #5 was admitted to the facility on 9/02/11. Review of the nursing admission assessment, completed on 9/02/11 at 10:01 p.m., revealed the patient's skin was intact.

On 9/03/11 at 11:21 a.m. the WCC assessed the patient and noted the patient had a gluteal cleft pressure ulcer, community acquired, measuring 2 x 0.2 x 0 cm, stage II, and partial thickness skin loss involving epidermis and/or dermis.

The admitting nurse failed to assess and identify the pressure ulcer to the gluteal cleft that was identified by the WCC on 9/03/11.

Review of the WCC documentation dated 9/28/11 revealed the patient had abrasions to the right buttock, measuring 6.5 x 6.5 x 0.1 cm and left buttock, measuring 8 x 4 x 0.1 cm. Review of the nursing shift assessments did not reveal observations of the right and left buttock abrasions or interventions initiated prior to being identified by the WCC on 9/28/11.

Further review of the record revealed on 11/09/11 the WCC assessed the patient and documented a pressure wound left posterior thigh 0.5 cm x 9.5 cm x 0 cm, stage II.

Review of the hospital acquired pressure ulcers log revealed patient #5 was identified on the log for a stage II to the left posterior thigh identified on 11/09/11. The comment section read "from temperature probe".

An interview with the WCC on 2/23/12 at 4:00 p.m. confirmed the patient acquired the stage II ulcer to the left posterior thigh from the plastic cover of a temperature probe. She stated it could not be determined how the cover of the temperature probe was left in the patient's bed.

3. Patient #10's admission nursing assessment was performed on 1/07/12 at 4:21 p.m. Documentation noted the patient's risk for pressure wounds using the Braden Scale was 15 indicating she was at low risk for developing pressure ulcers. Nursing documented the patient's activity level as immobile.

The admission nursing assessment dated 1/07/12 at 4:21 p.m. revealed the patient's skin was "intact." Documentation revealed on 1/07/12 at 8:00 p.m., three and one half hours following the admission assessment, the patient's skin was "not intact" but provided no further documentation of the location, size, or severity of the skin condition. Nursing documentation on 1/07/12 at 10:00 p.m., approximately five and one half hours following the admission assessment, revealed "skin not intact; pressure ulcer coccyx; unable to determine depth; pressure ulcer right buttocks". Review of the record revealed no documentation of interventions or treatment being initiated when the skin breakdown was identified.

Review of the medical record on 2/22/12 with the assistance of the nursing supervisor revealed no documentation within the medical record showing compliance with the facility policy.

Review of the facility's policy "Initial Wound Treatment", #H-WC 03-002, which stated the initial wound treatment provided options for the staff nurse to initiate wound care on newly admitted patients and those developing new wounds if the WCC is unavailable for immediate assessment of the patient's wounds. After initiating one of the options listed, refer to the WCC for follow-up evaluation and recommendations. The WCC will evaluate the patient within 72 hours of referral.

Review of the record revealed no documentation of the wounds having been cleansed or measured, any attempt to obtain physician orders for wound care as required by policy at the time of admission, or any nursing actions or approved intervention as stated in the policy.

Interview with the nursing supervisor on 2/22/12 at the time of the record review, approximately 4:30 p.m., confirmed the above findings.

Review of patient #10's nursing plan of care revealed nursing initiated "potential skin breakdown" based on the patient's Braden Score of 15 and immobility. Documentation revealed interventions included repositioning the patient every two hours.

Review of the nursing documentation revealed the first repositioning of the patient occurred at 4:00 a.m. on 1/08/12, approximately 12 hours following admission. Documentation dated 1/08/12 revealed repositioning was noted at the following times:
4:00 a.m.-reposition to right
5:41 a.m.-supine
8:00 a.m.-supine ( indicating the patient remained in the same position for over four hours) the patient was turned at 10:00 a.m. to the right side
9:57 p.m.-supine
On 1/09/12:
6:00 a.m.- supine
8:30 a.m.-right side (indicating the patient remained on her back for ten and one half hours from approximately 10:00 p.m. on 1/08/12 until being turned to her right side at 8:30 a.m. on 1/09/12.)

Review of the turning and repositioning documentation revealed nursing failed to ensure the patient was being turned and repositioned every 2 hours to prevent further skin breakdown per the plan of care.

Review of the record revealed no orders for wound care to the pressure wounds, present on admission on 1/7/2012 at 10:00 p.m., until the initial assessment by the WCC on 1/9/2012 at approximately 9:00 a.m., over 40 hours after admission.

The WCC documented on 1/9/2012 at approximately 9:00 a.m. that she noted the pressure wound on the coccyx to be Stage II and the others to be Stage I.

Review of the physician consultation on 1/11/12 revealed the patient's coccyx wound was unstageable, measuring 0.4 x 5 x 0.3 cm, 30% slough, and 70% pink. Review of the physician's wound progress note on 2/01/12 indicated the coccyx wound was obscured by necrotic area and slough and the patient would benefit from surgical debridement. Review of the physician progress note on 2/09/12 stated the patient underwent stage IV pressure ulcer excisional debridement.

Interview with the nursing supervisor on 2/22/12 at 4:30 p.m. confirmed the above findings.

4. Patient #6 was admitted on 10/25/11. Review of the nursing admission assessment, completed on 10/25/11 at 5:44 p.m. revealed the Braden Scale was assessed at 12 that indicated the patient was at high risk for skin impairment. Review of the admission nursing documentation revealed the skin had poor turgor, thin and was intact.

On 10/26/11 at 11:46 a.m. the WCC assessed the patient and documented the patient had a community acquired pressure ulcer to the right Achilles, stating a deep tissue injury. She documented ecchymosis to the left outer upper arm, a skin tear to the left inner upper arm and fissures to the right and left lower quadrant of the abdomen. There was no documentation by the admitting nurse of the skin conditions the WCC documented.

On 11/08/11 abrasions to the left and right buttock were identified by nursing. On 11/30/11 a pressure ulcer to the sacrum/buttocks was identified by nursing. The WCC assessed and measured the new ulcer to be 12.5 x 13.5 cm, it was obscured by necrosis and was unstageable. Review of the nursing documentation revealed no documentation the sacrum/buttocks had progressed to an unstageable ulcer prior to the wound being identified on 11/30/11.

An interview with the Chief Clinical Officer on 2/23/12 at 4:15 p.m. confirmed the above findings.

5. Patient #8 was admitted on 11/16/11. Review of the admission nursing assessment on 11/16/11 at 6:30 p.m. revealed the Braden Scale was 11, with multiple pressure ulcers identified upon admission to the right hip, left buttock, coccyx, perineum and an arterial ulcer on the right 5th toe.

Review of the weekly WCC assessment on 12/05/11 revealed a newly identified pressure ulcer to the left sacrum measuring 1 x 1 cm with necrotic tissue 100%. Review of the record revealed no documentation regarding nursing observation, assessment, intervention or care of the new wound prior to identification by the WCC on the weekly rounds.

6. Patient #9 was admitted on 12/13/11. Review of the initial nursing assessment revealed the patient's skin was thin, pale, with skin breakdown and with many abrasions. Nursing documentation revealed pressure ulcers to the urinary meatus, sacrum, perianal area, left hip and right hip.

Review of the WCC assessment on 12/30/11 revealed a right posterior heel blister measuring 6 x 5.5 cm. Review of the nursing documentation revealed no documentation of nursing observation, assessment or intervention prior to the WCC identifying the new ulcer on 12/30/11.

An interview with the Chief Clinical Officer on 2/23/12 at 4:30 p.m. confirmed the above findings.


7. On 2/22/12 at 11:10 a.m. a patient and an adult relative were interviewed.
The patient was alert and oriented, but had difficulty speaking. The adult relative stated she had been staying with the patient throughout the day, arriving usually about 9 a.m. and staying until 5 or 6:00 p.m. daily since mid-January.

In response to questions about the general nature of the care the patient and timeliness of response to call lights, the adult relative responded "Sometimes 15 minutes, sometimes an hour and a half (to answer the call light)". When asked how frequently the patient had to wait an hour and a half for assistance after turning on the call light, the relative answered "Their (the staff) favorite thing to do is come in and ask what we need, turn off the call light and tell us they, or someone, will be right back. I usually give them 5 minutes or so and turn the light on again".

In the presence of the surveyor, the relative turned on the call light after discovering the patient was incontinent. The time was noted to be 11:20 a.m. At 11:25 a.m. a staff member appeared in the open doorway and asked what did the patient need. The relative responded, "She needs to be changed, she's wet". The staff member then entered the room and turned off the call light by a switch located on the wall above the head of the bed, and informed the relative and patient she would let her aide know and he would be in shortly. After no one else had come, the relative turned the call light on again at 11:35 a.m. At 11:40 a.m. a different staff member appeared at the door and asked what was needed. The relative informed her. The second staff member entered the room and proceeded to turn off the call light a second time and leave after stating she would let the aid know and he would be with her soon. The next person to enter the room was a Respiratory Therapist. She said she had seen the call light on. She said the aide was just two rooms away and knew the patient needed assistance. At 11:48 a.m. the aide entered the room and began tending to the patient's needs, twenty eight minutes after the initial call.

Based on medical record review and staff interview it was determined the nursing staff failed to ensure the development and adherence to timely implementation of the individualized nursing plan of care for six (#1, #5,
#6, #8, #9, #10) of thirteen sampled patients. This practice does not ensure the patient goal to promptly identify and treat current or potential skin breakdown, placed the patients at risk for developing pressure ulcers or worsening of already identified pressure ulcers.

Findings include:

1. Patient #1 was admitted to the facility on 12/02/11. Review of the nursing admission assessment completed on 12/02/11 at 9:07 p.m. revealed the patient was bed bound. The nursing assessment revealed the patient had a left below the knee amputation and was immobile.

Review of the nursing admission assessment revealed the patient's skin on admission was intact. The Braden Scale assessment upon admission was 12 that indicated the patient was at high risk for skin breakdown.

Review of nursing documentation revealed on 12/16/11, two weeks after admission, nursing assessed the patient to have a wound to the buttock crease measuring 4 x 2 x 0.1 cm (centimeters). Documentation revealed on 12/16/11 a referral for the wound care nurse was placed. Review of the record revealed the wound care nurse assessed the patient on 12/21/11, five days after the referral.

Review of the facility's policy, "Initial Wound Treatment" , #H-WC 03-002, states the Wound Care Coordinator (WCC) will evaluate the patient within 72 hours of referral.

On 12/21/11 at 3:04 p.m. the WCC assessed the patient. Documentation revealed the patient had a hospital acquired gluteal fold ulcer, stage III. Documentation revealed no additional wound interventions except the barrier cream which was still being applied as evidenced by daily nursing documentation.

Nursing failed to update the nursing plan of care, to initiate interventions for a worsening pressure ulcer.

Interview with the WCC on 2/22/12 at 3:30 p.m. confirmed the barrier cream was the only intervention being applied to the gluteal ulcer from 12/21/11 to 1/18/12.

On 1/23/12 at 5:26 p.m. the WCC reassessed the patient. Documentation revealed the patient had a hospital acquired ulcer to the gluteal fold measuring 2.7 x 0.7 x 0.1 cm, stage III. Physician orders on 1/23/11 were obtained for wound care.

On 1/25/12 the wound care physician assessed the patient's ulcer. The physician assessed the patient to have right buttock excoriation with small punctuate area on the right. On the left buttock there was complete dermal loss with good epithelization. In the gluteal cleft there was a small wound measuring approximately 18 x 5 mm (millimeters) wide, pink with good granulation at the base.

On 1/27/12 the wound care nurse assessed the patient at 1:18 p.m. Documentation revealed the gluteal fold ulcer measuring 2.7 x 0.7 x 0.1 cm, stage III. There was no documentation of the right or left buttock excoriation that was assessed by the wound care physician on 1/25/11.

On 2/03/12 at 11:50 a.m. the wound care nurse assessed the patient. The gluteal fold ulcer was assessed and measured and noted to be unchanged from the 1/27/11 assessment. Documentation revealed a hospital acquired left buttock ulcer, stage II. There was no documentation by the wound care nurse of excoriation to the right buttock as documented by the physician on 1/25/11.

On 2/08/12 the wound care physician assessed the patient. The physician documented the patient had a stage IV pressure wound of the coccyx and would undergo debridement that day. .

On 2/09/12 at 2:54 p.m. the wound care nurse assessed the patient. The gluteal fold ulcer was assessed and documented as a stage III. Documentation revealed the left buttock ulcer was a stage III. There was no documentation of the right buttock or nursing interventions or the care plan updated for the right buttock.

2. Patient #5's nursing admission assessment completed on 9/02/11 at 10:01 p.m. revealed the patient ' s skin was intact.

On 9/03/11 at 11:21 a.m. the WCC assessed the patient and noted the patient had a gluteal cleft pressure ulcer, community acquired, measuring 2 x 0.2 x 0 cm, stage II. The admitting nurse failed to assess and identify the pressure ulcer to the gluteal cleft that was identified by the WCC on 9/03/11.

Review of the WCC documentation dated 9/28/11 revealed the patient had abrasions to the right buttock, measuring 6.5 x 6.5 x 0.1 cm and left buttock, measuring 8 x 4 x 0.1 cm. Review of the nursing shift assessments did not reveal observations of the right and left buttock abrasions or interventions initiated prior to being identified by the WCC on 9/28/11.

3. Patient #10's admission nursing assessment was performed on 1/07/12 at 4:21 p.m. Nursing assessed the patient's risk for pressure wounds using the Braden Scale and documented 15 indicating she was at low risk for developing pressure ulcers. Nursing documented the patient's activity level as immobile.

The admission nursing assessment dated 1/07/12 at 4:21 p.m. revealed the skin was intact. Documentation revealed on 1/07/12 at 8:00 p.m., three and one half hours following the admission assessment, the skin was " not intact. There was no further documentation of the location, size, or severity of the skin condition. Nursing documentation on 1/07/12 at 10:00 p.m., approximately five and one half hours following the admission assessment revealed a pressure ulcer coccyx; unable to determine depth; pressure ulcer right buttocks. Review of the record revealed no documentation interventions or treatment was initiated when the skin breakdown was identified.

Review of the medical record on 2/22/12 with the assistance of the nursing supervisor revealed no documentation within the medical record showing compliance with the facility policy for "Initial Wound Treatment" , #H-WC 03-002, which stated the initial wound treatment provides options for the staff nurse to initiate wound care on newly admitted patients and those developing new wounds if the WCC is unavailable for immediate assessment of the wounds. After initiating one of the options listed, refer to the WCC for follow-up evaluation and recommendations.

Review of the record revealed no documentation of the wounds having been cleansed, photographed or measured, any attempt to obtain physician orders for wound care at the time of admission or any nursing actions or approved intervention.

Interview with the nursing supervisor on 2/22/12 at the time of the record review, approximately 4:30 p.m., confirmed the above findings.

Patient #10's nursing plan of care revealed nursing initiated "potential skin breakdown" based on the Braden Score of 15 and immobility. Documentation revealed interventions included repositioning the patient every two hours. Review of the medical record revealed that the first repositioning of the patient occurred at 4:00 a.m. on 1/08/12, approximately 12 hours following admission. Documentation dated 1/08/12 revealed repositioning was noted at the following times:
4:00 a.m.-reposition to right si
5:41 a.m.-supine
8:00 a.m.-supine ( indicating the patient remained in the same position for over four hours). The patient was turned at 10:00 a.m. to the right side.
9:57 p.m.-supine
On 1/09/12:
6:00 a.m.-supine (indicating the patient remained on her back for ten and one half hours from approximately 10:00 p.m. on 1/08/12 until being turned to her right side at 8:30 a.m. on 1/09/12.)

Review of the turning and repositioning revealed nursing failed to ensure the patient was being turned and repositioned every 2 hours to prevent further skin breakdown as indicated in the nursing plan of care.

Review of the documentation further revealed no documentation of wound care being performed. Review of the record revealed no orders for wound care to the pressure wounds, present on admission 1/7/2012 at 10:00 p.m., until the initial assessment by the Wound Care Nurse on 1/9/2012 at approximately 9:00 a.m., over 40 hours after admission.

Review of the physician progress note on 2/09/12 stated the patient underwent stage IV pressure ulcer excisional debridement.

Interview with the nursing supervisor on 2/22/12 at 4:30 p.m. confirmed the above findings.

4. On 2/22/12 at 11:10 a.m. a patient and an adult relative were interviewed.
The patient was alert and oriented, but had difficulty speaking. The adult relative stated she had been staying with the patient throughout the day, arriving usually about 9 a.m. and staying until 5 or 6:00 p.m. daily since mid-January.

In response to questions about the general nature of the care the patient and timeliness of response to call lights, the adult relative responded "Sometimes 15 minutes, sometimes an hour and a half (to answer the call light)". When asked how frequently the patient had to wait an hour and a half for assistance after turning on the call light, the relative answered "Their (the staff) favorite thing to do is come in and ask what we need, turn off the call light and tell us they, or someone, will be right back. I usually give them 5 minutes or so and turn the light on again".

In the presence of the surveyor, the relative turned on the call light after discovering the patient was incontinent. The time was noted to be 11:20 a.m. At 11:25 a.m. a staff member appeared in the open doorway and asked what did the patient need. The relative responded, "She needs to be changed, she's wet". The staff member then entered the room and turned off the call light by a switch located on the wall above the head of the bed, and informed the relative and patient she would let her aide know and he would be in shortly. After no one else had come, the relative turned the call light on again at 11:35 a.m. At 11:40 a.m. a different staff member appeared at the door and asked what was needed. The relative informed her. The second staff member entered the room and proceeded to turn off the call light a second time and leave after stating she would let the aid know and he would be with her soon. The next person to enter the room was a Respiratory Therapist. She said she had seen the call light on. She said the aide was just two rooms away and knew the patient needed assistance. At 11:48 a.m. the aide entered the room and began tending to the patient's needs, twenty eight minutes after the initial call.

5. Patient #6's nursing admission assessment, completed on 10/25/11 at 5:44 p.m. revealed the Braden Scale was assessed at 12 that indicated the patient was at high risk for skin impairment. Review of the admission nursing documentation revealed the skin was intact.

On 10/26/11 at 11:46 a.m. the WCC assessed the patient and documented the patient had a community acquired pressure ulcer to the right Achilles, stating a deep tissue injury. She also documented ecchymosis to the left outer upper arm, a skin tear to the left inner upper arm and fissures to the right and left lower quadrant of the abdomen. There was no documentation by the admitting nurse of the skin conditions the WCC documented.

On 11/08/11 abrasions to the left and right buttock were identified by nursing. Documentation revealed barrier cream was applied twice daily and as needed.

On 11/30/11 a pressure ulcer to the sacrum/buttocks was identified by nursing. The WCC assessed and measured the new identified ulcer to be 12.5 x 13.5 cm, documented it was obscured by necrosis and was unstageable. Review of the nursing documentation revealed no documentation the sacrum/buttocks had progressed to an unstageable ulcer prior to the wound being identified on 11/30/11.

An interview with the Chief Clinical Officer on 2/23/12 at 4:15 p.m. confirmed the above findings.

6. Patient #8's admission nursing assessment on 11/16/11 at 6:30 p.m. revealed the Braden Scale was 11, with multiple pressure ulcers identified upon admission to the right hip, left buttock, coccyx, perineum and an arterial ulcer on the right 5th toe.

Review of the weekly WCC assessment on 12/05/11 revealed a newly identified pressure ulcer to the left sacrum measuring 1 x 1 cm with necrotic tissue. Review of the record revealed no documentation regarding nursing observation, assessment, intervention or care of the new wound prior to identification and intervention by the WCC on the weekly rounds.

7. Patient #9's initial nursing assessment revealed skin breakdown, with many abrasions. Nursing documentation revealed pressure ulcers to the urinary meatus, sacrum, perianal area, left hip and right hip.

Review of the WCC assessment on 12/30/11 revealed a right posterior heel blister measuring 6 x 5.5 cm. Review of the nursing documentation revealed no documentation of nursing observation, assessment, intervention prior to the WCC identifying the new ulcer on 12/30/11.

An interview with the Chief Clinical Officer on 2/23/12 at 4:30 p.m. confirmed the above findings.

Based on staff interview and review of quality assessment performance improvement indicators it was determined that the facility failed to implement accurate monitoring of areas that are found to be problem prone relative to identification and assessment for development or worsening of pressure ulcers. The facility's failure to implement ongoing and accurate monitoring of the identified problem prone patient care issue places patients at risk for the development and worsening of pressure ulcers leading to a potential decline in the patient's health status.

Findings include:

On 2/23/12 at 4:30 p.m. an interview with the Chief Clinical Officer and the Wound Care Coordinator was conducted. The interview revealed pressure ulcers were identified as a high risk indicator identified by the patient population. It was determined patients identified with pressure ulcers were monitored weekly by the Wound Care Coordinator (WCC). Nursing shift assessment were to assess, identify and monitor the patient's skin for any skin alteration.

Review of six of thirteen medical records revealed patient's skin was not accurately assessed, pressure ulcers were not identified and the wound care coordinator failed to monitor patient's skin on a weekly basis.

1. Review of the record for patient #1 revealed the patient was admitted to the facility on 12/02/11. Review of the nursing admission assessment completed on 12/02/11 at 9:07 p.m. revealed the patient's skin on admission was intact. Review of the record revealed on 12/05/11 the wound care nurse assessed the patient. Documentation revealed no skin breakdown.

Review of the nursing documentation revealed on 12/16/11, two weeks after admission, nursing assessed the patient to have a wound to the buttock crease. Documentation revealed on 12/16/11 a referral for the wound care nurse was placed. Review of the record revealed the wound care nurse assessed the patient on 12/21/11, five days after the referral.

Review of the facility's policy, "Initial Wound Treatment" , #H-WC 03-002, stated the Wound Care Coordinator (WCC) will evaluate the patient within 72 hours of referral.

On 12/21/11 at 3:04 p.m. the WCC assessed the patient. Documentation revealed the patient had a hospital acquired gluteal fold ulcer, stage III.

Review of the record revealed the WCC reassessed the patient on 1/13/12, which was three weeks and two days from the previous assessment.

Review of the facility's policy, "Wound Assessment and Classification", #H-WC 02-001, stated weekly assessments will be conducted by the WCC.

Review of the record revealed photographs, dated 1/13/12, of the documented gluteal fold ulcer, right buttock and left buttock. Documentation by the WCC on 1/13/12 revealed a gluteal fold ulcer, stage III, hospital acquired ulcer. There was no documentation by the WCC of the right or left buttock which was photographed on 1/13/12.

On 1/25/12 the wound care physician assessed the patient's ulcer. The physician assessed the patient to have right buttock excoriation with small punctuate area on the right. On the left buttock there was complete dermal loss with good epithelization. In the gluteal cleft there was a small wound measuring approximately 18 x 5 mm (millimeters).

On 1/27/12 the wound care nurse assessed the patient at 1:18 p.m. Documentation revealed the gluteal fold ulcer. There was no documentation of the right or left buttock excoriation that was assessed by the wound care physician on 1/25/11.

On 2/03/12 at 11:50 a.m. the wound care nurse assessed the patient. The gluteal fold ulcer was assessed. Documentation revealed a hospital acquired left buttock ulcer. There was no documentation by the wound care nurse of excoriation to the right buttock as documented by the physician on 1/25/11.

On 2/09/12 at 2:54 p.m. the wound care nurse assessed the gluteal fold ulcer and the left buttock ulcer. There was no documentation of the right buttock.

2. Review of the medical record for sample patient #5 revealed the patient was admitted to the facility on 9/02/11. Review of the nursing admission assessment on 9/02/11 at 10:01 p.m. revealed the patient's skin was intact.

On 9/03/11 at 11:21 a.m. the WCC assessed the patient and noted the patient had a gluteal cleft pressure ulcer, community acquired. The admitting nurse failed to assess and identify the pressure ulcer to the gluteal cleft.

Review of the WCC documentation dated 9/28/11 revealed the patient had abrasions to the right buttock. Review of the nursing shift assessments did not reveal observations of the right and left buttock abrasions.

Further review of the record revealed on 11/09/11 the WCC assessed the patient and documented a pressure wound left posterior thigh. Review of the hospital acquired pressure ulcers log revealed patient #5 was identified on the log for a stage II to the left posterior thigh identified on 11/09/11. The comment section read "from temperature probe".

An interview with the WCC on 2/23/12 at 4:00 p.m. confirmed the patient acquired the stage II ulcer to the left posterior thigh from the plastic cover of a temperature probe. She stated it could not be determined how the cover of the temperature probe was left in the patient's bed.

3. Review of the record for sampled patient #10 revealed the admission nursing assessment was performed on 1/07/12 at 4:21 p.m. The patient's skin was intact. Documentation revealed on 1/07/12 at 8:00 p.m. revealed three and one half hours following the admission assessment, the skin was not intact. There was no further documentation of the location, size, or severity of the skin condition.

Interview with the nursing supervisor on 2/22/12 at the time of the record review, approximately 4:30 p.m., confirmed the above findings.

4. Review of the medical record for sampled patient #6 revealed the patient was admitted on 10/25/11. Review of the nursing admission assessment on 10/25/11 at 5:44 p.m. revealed the skin was intact.

On 10/26/11 at 11:46 a.m. the WCC assessed the patient and documented the patient had a community acquired pressure ulcer to the right Achilles, stating a deep tissue injury. She also documented ecchymosis to the left outer upper arm, a skin tear to the left inner upper arm and fissures to the right and left lower quadrant of the abdomen. There was no documentation by the admitting nurse of the skin conditions the WCC documented.

Review of the nursing documentation revealed no documentation the sacrum/buttocks had progressed to an unstageable ulcer prior to the wound being identified on 11/30/11.

An interview with the Chief Clinical Officer on 2/23/12 at 4:15 p.m. confirmed the above findings.

5. Review of the medical record for sampled patient #8 revealed the patient was admitted on 11/16/11. Review of the admission nursing assessment on 11/16/11 at 6:30 p.m. revealed the patient had multiple pressure ulcers identified upon admission.

Review of the weekly WCC assessment on 12/05/11 revealed a newly identified pressure ulcer to the left sacrum.

Review of the record revealed no documentation regarding nursing observation or assessment of the new wound prior to identification and intervention by the WCC on the weekly rounds.

6. Review of the medical record for sampled patient #9 revealed the patient was admitted on 12/13/11. Review of the initial nursing assessment revealed the patient had skin breakdown with many abrasions.

Review of the WCC assessment on 12/30/11 revealed a right posterior heel blister. Review of the nursing documentation revealed no documentation of nursing observation or assessment prior to the WCC identifying the new ulcer on 12/30/11.

An interview with the Chief Clinical Officer on 2/23/12 at 4:30 p.m. confirmed the above findings.

There was no evidence the facility was monitoring the nursing documentation or implementing an action plan of new pressure ulcer identification or worsening of the pressure ulcers or for the WCC not following policy and procedure for the identified problem prone area.