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Based on record review and interview the hospital failed to ensure that 1 (Patient #1) of 10 patients sampled received an updated nursing plan of care, specific to a nursing re-assessment after a return to the unit per hospital policy. The hospital failed to ensure that wound care was documented as ordered by the patient's physician for Patient #1.

Findings:

A review of the hospital's policy titled : assessment/Re-assessment" last reviewed dated 02/20/2014 revealed that patient reassessment is based on but not limited to the following. To evaluate patient response to care. treatment and services.

Record review for Patient #1 revealed that the patient was transferred to the long term care hospital on 7/14/14. The patient had multiple medical problems including paraplegia, chronic right ankle wound, non-Hodgkin ' s lymphoma, systemic lupus, deep venous thrombosis, and pulmonary embolism. A review of the nurse's admission note revealed that the patient had the following wounds on admission: right buttock 0.7 cm length by 3 cm width by 0.1 cm depth stage 2 pressure ulcer and right lateral ankle 7.8 cm length, by 1.5 cm width wound dehiscence.

A review of the physician's orders revealed that the following wound care was ordered on admission: " pressure ulcer to right buttock clean with wound cleanser and apply foam dressing daily. Right lateral ankle dressing apply wet to dry dressings daily."

A review of the nurse's notes revealed that on 7/14/14 the wound assessment was completed by the nurse and the wound care was performed. The nurse documented on 7/16/14 that the patient refused the daily wound care. The wound care nurse documented on 7/17/14 that the patient refused wound care and skin assessment. There was no documentation in the nurse's notes on 7/15/14, 7/18/14, 7/19/14, 7/20/14, and 7/21/14 that Patient #1 refused the wound care or if the wound care was performed.

An interview with the director of Nursing ( DON ) on 9/11/14 at 11:30 AM she stated that there was no documentation by the nurse concerning wound care for Patient #1 on 7/15/14, 7/18/14, 7/19/14, 7/20/14, and 7/21/14.

The nurse documented on 7/21/14 at 4:30 PM that Patient #1 was transferred to a hospital (located within the same building) for a CT ( Computed Tomograpy- An image of a detailed cross section of tissue) of the abdomen with contrast. There were no nurse's notes or re-assessment notes of Patient #1's condition upon return from the CT scan.

In reviewing nurse's notes documented on 7/21/14 at 5:50 PM the patient was found unresponsive and not breathing. A " code blue" ( Specially trained team of professional who do cardiopulmonary resuscitation) was called and CPR ( cardiopulmonary resuscitation) was initiated. The code team and physician responded. The nurse noted that the patient's mother asked that the code be stopped as her daughter did not want to be intubated (breathing tube placement).

An interview with the Director of Nursing ( DON) on 9/11/14 at 11:30 AM she stated that there was no documentation by the nurse concerning wound care for Patient #1 on 7/15/14, 7/18/14, 7/19/14, 7/20/14, and 7/21/14. The DON stated that on 7/21/14 Patient #1 went into cardiac arrest at 5:50 PM. She stated that the patient was found unresponsive and CPR was started immediately. The mother of the patient was present at the bedside at the time of the cardiac arrest. The DON stated that code was stopped at the request of Patient #1's mother. The DON stated that the mother stated that her daughter would not want to be on a ventilator. The DON confirmed that there was no reassessment notes by the nurse indicating the patient's condition upon return to her room after the CT scan. The surveyor requested to interview Nurse A on the day of the survey. The DON stated that the nurse was on vacation during the week of the survey and unavailable for interview.