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Based on interview and record review, the facility failed to notify/inform patient #1's state guardian when patient #1 sustained changes in the patient's medical condition. Patient #1 was admitted to the facility on January 19, 2010, with no pressure ulcers. Interview and record review revealed patient #1 developed a pressure ulcer behind the left ear on January 26, 2010. Patient #1 also developed pressure ulcers to the sacrum and both heels on January 29, 2010. The state guardian was not notified/informed of patient #1's health status until February 17, 2010, when permission was requested to provide surgical debridement of the sacrum wound.

The findings include:

Review of the facility's policy for Consent to Treatment revealed the facility had guidelines for obtaining general consent for treatment or informed consent for treatment, when appropriate, from the patient or patient's legal representative. Further review of the policy revealed every individual had the right through his/her own decision-making or through the decision of his/her representative to informed participation in decisions involving health care. Inherent to this right was the right to make informed decisions to accept or refuse treatment; to formulate advanced directives and appoint a surrogate to make health care decisions on his/her behalf. To the degree possible, no individual should be subjected to any medical treatment or procedure without his/her legal representative's consent according to the policy.

Review of the facility's Patient Rights policy revealed patients and their designated surrogate had the right to: (a) Receive personalized treatment through an individual treatment plan and participate in the development and implementation of the treatment plan. (b) The institution valued each patient's cultural, racial, and religious heritage as part of the plan. Formulate advance directives (living will, durable power of attorney, healthcare surrogate, etc.) and hospital staff/practitioners were to comply with these directives in accordance with federal and state law. (c) Make informed decisions regarding care, including being informed of health status; being involved in care planning and treatment; being able to request or refuse treatment to the extent permitted by law, and to be told of the medical consequences of the patient's actions.

Review of patient #1's medical record revealed the patient was admitted to the facility on January 19, 2010, with a diagnosis that included pneumonia, respiratory failure, and hypertension. Review of the initial nursing assessment dated January 20, 2010, revealed the patient did not have any skin breakdown at the time of admission. Further review of the medical record revealed permission was received by phone from the guardian for the admission. On January 26, 2010, a wound nurse consultation was conducted and treatment was initiated for a pressure ulcer behind the patient's left ear. On January 29, 2010, the wound care nurse noted patient #1 had pressure ulcers to both heels and a pressure ulcer to the sacrum. On January 30, 2010, the area to the sacrum area was assessed by staff to be a Stage II pressure ulcer. Patient #1 was transferred to Oak Tree Hospital, a Long Term Acute Care (LTAC) facility, on February 4, 2010. There was no documentation found in the medical record that the state guardian had been informed of patient #1's change in health status (development of pressure ulcers).

Wound Care Nurse (WCN #1) stated in interview on March 31, 2010, at 12:45 p.m., that a wound care consultation was conducted for patient #1 on three occasions on January 26, 2010, January 29, 2010, and January 30, 2010. WCN #1 stated patient #1 developed pressure ulcers to the patient's left ear, sacrum, and both heels. WCN #1 stated treatment was provided for patient #1's pressure ulcers. WCN #1 gave no explanation why patient #1's state guardian was not notified of patient #1's pressure ulcers.

RN #1 stated in interview on March 31, 2010, at 2:00 p.m., that a skin assessment was conducted on each patient every shift. RN #1 provided care for patient #1 on January 27, 2010, and documented the patient had reddened areas on both heels and the sacrum which were nonblanchable (poor circulation present). RN #1 stated patient #1's sacrum area had developed an open wound on January 30, 2010, but the tissue looked healthy. RN #1 stated pillows were placed under the patient heels and wound care was provided. RN #1 did not notify the state guardian of patient #1's open wound. RN #1 stated staff normally called the state guardians when patients were transferred but did not notify the state guardian when a patient developed a pressure ulcer.

RN #2 stated in interview on March 31, 2010, at 4:00 p.m., that patient #1 was discharged from the Acute Care Hospital on February 4, 2010, and admitted to the LTAC hospital due to the patient needing further intravenous antibiotic treatment for pneumonia. RN #2 stated the accepting hospital was informed of the patient's pressure ulcers at the time of transfer. RN #2 stated the state guardian was informed of the transfer but was not informed of patient #1's pressure ulcers. When asked why the state guardian was not informed of the pressure ulcers, RN #2 stated, "That wasn't the reason for the transfer." According to RN #2, nursing staff normally did not inform guardians of the development of pressure ulcers.

The LTAC Director of Nursing (DON #2) stated in interview on March 31, 2010, that the state guardian was not informed of patient #1's wounds. DON #2 stated the patient came to the LTAC facility with the pressure sores and LTAC staff "assumed" the Acute Care Hospital had already informed the state guardian of patient #1's wounds. DON #2 stated LTAC staff felt the patient's wounds were not going to heal without surgical debridement so telephone consent was requested for surgical debridement from the state guardian on February 17, 2010. DON #2 stated consent was never obtained. DON #2 stated the patient's state guardian requested that patient #1 be transferred to another facility.