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Based on interview and documentation review the Hospital did not include a plan to observe staff and/or patients at risk for pressure sore development for compliance after education was provided to staff regarding assessing patients at risk for pressure sore development.

Findings included:

The following was reported: the Patient (Patient #1), who had metastatic cancer, was admitted to the Hospital on 5/24/10 with shortness of breath and arrhythmias. Patient #1 was assessed on admission as at risk for skin breakdown and interventions including repositioning, skin inspections, and incontinence care were implemented. Patient #1's medical condition deteriorated with complications of hypotension, neutropenia, low albumin levels, and thrombocytopenia. On 5/28/10 Patient #1's skin was inspected and five wounds were discovered, three of which were small Stage III pressure related wounds ( full thickness skin loss involving damage to or necrosis of subcutaneous tissue extending to underlying fascia; presents as a crater with/without undermining) measuring 0.8 centimeters (cm) x 0.5cm, 1.8cm x 0.5cm, and 0.2cm x 1cm respectively. A wound consult was obtained and treatments were implemented. Patient #1's medical condition continued to deteriorate, comfort measures only was activated, and Patient #1 expired on 6/3/10.

A tour of the Unit the Patient was on was conducted on 6/16/10. Observation determined the Unit used pressure redistribution mattresses (a dense foam mattress) on all beds unless otherwise ordered.

The staff assigned to Patient #1 were interviewed as follows: Nurse #1 was interviewed on 6/16/10 at 10:10 A.M.; Nurse #2 was interviewed on 6/16/10 at 2:45 P.M.; Certified Nurse Aide (CNA) #1 was interviewed on 6/16/10 at 1:35 P.M.; CNA #2 was interviewed on 6/16/10 at 1:40 P.M., and CNA #3 was interviewed on 6/17/10 at 5:55 A.M. Interviews indicated that Patient #1's skin was not assessed and/or was not thoroughly assessed.

The Hospital's Wound/Ostomy Nurse and the Director of the unit Patient #1 was on were interviewed on 6/16/10 respectively at 10:20 A.M. and 2:00 P.M. and the corrective action plan was reviewed. The Director said during the investigation it was determined the nurse who admitted Patient #1 (not available during the survey) asked Patient #1 about the skin condition rather than assessed Patient #1's skin. The corrective action plan included education (regarding identification, assessment, and documentation), implementation of formalized committee meetings, chart audits, and ongoing coaching regarding assessment and documentation. The action plan did not include a follow-up plan, such as observations, to ensure that once education was completed, staff were appropriately assessing the skin of patients identified as at risk for pressure sore development.