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Based on record review and interview, the facility failed to ensure staff and practitioners comply with the patients' advance directives in 1 out 10 Sample Patients (SP). (SP#1).

The findings include:

Record review for SP#1 conducted from 09/20/2012 to 09/21/2012 revealed that SP#1 ' s wife signed all consents for procedures. However, there is no documentation of a Advance Directives noted in record.

During interview with SE#2 conducted on 09/21/2012 at 09:34 A.M., SE#2 stated that in respects to " Do Not Resuscitate (D.N.R.) " discussion with SP#1 ' s wife was, it was pretty clear from day 1 she never wanted us to stop antibiotic, ventilator. It [D.N.R.] was not warranted. We did talk about how advanced the disease and how it was progressing. Never felt comfortable approaching with her because she was very mad/confrontational due to patient ' s advance disease.

Telephone call from Associate Director of Quality Management received on 09/28/2012 at 11:00 A.M. revealed the facility is unable to retrieve consent for treatment or advance directive for SP#1.

Based on observation, interview and record review, the facility failed to provide care in a safe setting for 4 out 6 sampled patients (SP) that were in the need of wound care. (SP#1, SP#6, SP#7 and SP#10).

The findings include:

1. Clinical record review of SP#1 conducted from 09/20/2012 to 09/21/2012 showed SP#1 was admitted on 06/20/2012 to the S.C.U. at the facility. SP#1 was discharged (D/C) from the facility on 08/04/2012. Review of the Nurse Progress note written on 07/19/2012 at 12:52 P.M. states the nurse informed SE#2 of ulcer. Review of the physician orders dated 07/20/2012 showed " wound care evaluation " . On 07/24/2012 and 07/25/2012, the nurse documented " pressure ulcer stage II " . Review of the wound care nurse orders written on 07/25/2012 a 03:40 P.M.
showed wound care evaluation was done and the following was ordered " cleanse with soap and water then rinse well. Apply thin coat Bactroban and dry dressing. Change dressing daily. Continue with air mattress. Turn and reposition patient every 2 hrs [hours] " . There is inconsistency in assessment of wound and its characteristics . The documentation does not show progress of wound as documented in assessments) so that desired outcome is measurable.

Interview with SE#12 conducted on 09/20/2012 at 04:15 P.M. revealed that facility has 1 wound care nurse. As per SE#12 " because of the amount of wounds, the nurse tries to prioritize the wounds to see. No wound care done on Saturday and Sunday because the department is closed. " When surveyor asked regarding SP#1 ' s consult, SE#12 stated it does not warrant any consult because its outside of our policy. The patient was seen on Wednesday. We try to honor the order/request as soon as possible. Per policy, consults are generated for stages III and above " .

2. Clinical record review of SP#6 conducted from 09/20/2012 to 09/21/2012 showed SP#6 was admitted on 09/07/2012 to the facility. Review of the physician orders dated 09/07/2012 at 23:05 pm showed " wound care evaluation " . Further review of the nursing documentation showed inconsistent documentation of wound/skin condition.

3. Clinical record review of SP#7 conducted from 09/20/2012 to 09/21/2012 showed SP#6 was admitted on 09/11/2012 to the facility. Review of the physician orders dated 09/11/2012 at 12:30 pm showed " wound care evaluation " . Review of the wound care evaluation showed it was done 09/20/2012 at 04:50 P.M. Further review of the nursing documentation showed inconsistent documentation of wound/skin condition.

4. Clinical record review of SP#10 conducted from 09/20/2012 to 09/21/2012 showed SP#10 was admitted on 09/11/2012 to the facility. Review of the physician orders dated 07/05/2012 at 19:00 pm showed " wound care evaluation " . Review of the wound care evaluation showed it was done 07/11/2012 at 04 P.M. Further review of the nursing documentation showed inconsistent documentation of wound/skin condition.

Interview with SE#14 conducted 09/21/2012 at 02:10 P.M. in the presence of the Associate Director of Quality Management confirmed above findings. The delay in wound care evaluation and inconsistency in documentation can compromise the patient's status and have significant impact in patient's outcome.