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Based on medical record review and staff interview the facility failed to assess the patients' skin integrity for four (4) of 20 sampled patient's (Patient #s 3, 4, 7, and 9) according to their action plan and failed to provide turning and repositioning for three (3) of 20 sampled patients who were at risk for developing pressure sores (Patient #s 1, 3, and 9). The patient census was 194.

The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' nursing needs would be met. (See A 395)

Based on medical record review and staff interview the facility failed to assess the patients' skin integrity for four (4) of 20 sampled patient's (Patient #s 3, 4, 7, and 9) according to their action plan and failed to provide turning and repositioning for three (3) of 20 sampled patients who were at risk for developing pressure sores (Patient #s 1, 3, and 9). The patient census was 194.

Findings include:

Review of the medical record of Patient #1 on 01/10/12, revealed this patient was admitted to the hospital with a diagnosis of hip fracture resulting in hip surgery that occurred on 11/16/11. The patient was assessed as being at moderate risk for pressure sores. A physical therapy evaluation dated 11/17/11, revealed documentation that Patient #1 required moderate assistance moving to the right side. Review of the turn and reposition documentation from 11/16/11 through 11/20/11, revealed there was no documentation patient #1 was turned and repositioned every two hours. On 11/16/11, the patient's medical record revealed the patient was in the supine (back) position from 4:45 PM until 10:00 PM. On 11/18/11, the patient was documented as being in the supine position from 8:00 PM until 7:20 AM 11/19/11. These findings were confirmed by staff B on 01/10/12 at 2:00 PM.

Review of the medical record of Patient #3 on 01/09/12, revealed this patient was admitted to the hospital under observation status from 11/17/11 to 11/19/11 and had a diagnosis of Paraplegia. At the time of this patient's nursing assessment for the patient's skin integrity on 11/17/11, documentation revealed the patient had a tailbone ulcer measuring 3 centimeters by 2 centimeters, an abrasion on the right lateral left leg measuring 4 centimeters by 4 centimeters by 1 centimeter, and an open perineal groin area that documentation revealed was not measured. Review of the wound care nurse's (Staff A) assessment dated 11/18/11, revealed Patient #3 had an open area on the tailbone measuring 1 centimeter by 1 centimeter and 1.5 centimeters, a left gluteal stage four ulcer measuring 2 centimeters by 2 centimeters by 1 centimeter, a left lateral post thigh pressure sore at a stage two, and a left posterior leg pressure area with suspected deep tissue injury . The documentation included a statement from the patient that the left posterior leg area was caused "by the wheelchair"

Staff A and Staff B confirmed the discrepancies in Patient #3's wound assessments during an interview on 01/10/12, at 11:00 AM. Further interview of Staff B on 01/09/12, at 4:00 PM revealed pressure sore assessment discrepancies had been identified in June 2011, by the wound care nurse (Staff A). Review of Quality Review Action plans on 01/10/12, revealed this was brought to the Quality Assurance Committee on 06/27/11, and that actions to reduce hospital acquired pressure sores was to have two staff, (RN/RN or RN/PCT) to check skin on admission with one staff documenting. The status results for this action plan dated 07/22/11 revealed all inpatient units have initiated/monitoring effectiveness. The results dated 08/12/11, indicated that all units are compliant. The results dated 10/11/11, revealed each unit is monitoring and some units require both to document. The results dated 11/11/11, revealed unit monitoring and Midas (computer program that collects quality data) reveals improvement with Plan of Action, but still needs to continue to improve and most units are requiring second verifier to document. There was no documentation staff were inserviced on the facility's action plan for pressure sore assessments until 11/29/11 through 12/19/11, although this issue had been determined to be a compliance issue in June, 2011.



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Review of the medical record for Patient #4 was completed the afternoon of 01/10/12. The medical record revealed the patient was admitted to the hospital on 01/03/12, and the skin assessment was completed on 01/03/12, at 4:19 PM by a registered nurse. The skin assessment revealed there were no skin problems on admission. Further review of the medical record revealed patient #4's skin assessment was not verified by a second registered nurse according to the facility's action plan implemented in June 2010. This finding was shared with Staff B the afternoon of 01/10/12.

Review of the medical record for Patient #7 was completed the afternoon of 01/10/12. The medical record revealed the patient was admitted to the hospital on 01/04/12, and the skin assessment was completed on 01/04/12 at 2:32 PM. Further review of the medical record revealed patient #7's skin assessment was not completed by a second registered nurse according to the facility's action plan implemented in June 2011. This finding was shared with Staff B the afternoon of 01/10/12.

Review of the medical record for Patient #9 was completed the afternoon of 01/10/12. The medical record revealed the patient was admitted to the hospital with a right hip fracture and had surgery for a hip fracture on 11/04/11. The medical record revealed the patient's skin assessment was completed on 11/04/11 (admission date), but was not verified by a second registered nurse according to the facility's action plan implemented in June 2011. The medical record revealed the patient did not have any skin problems on admission and had a skin risk of sixteen for skin breakdown. The skin risk assessment revealed anything greater than sixteen was considered high risk for skin breakdown. Review of the medical record revealed on 11/05/11, the patient's skin risk score was nineteen, making the patient a high risk for skin breakdown.

Review of the medical record revealed after the patient's hip surgery on 11/04/11, the patient was independent with turning his/her upper extremities, but was restricted for lower body turning. Further review of the medical record revealed on 11/07/11, Patient #9 was discharged to in house rehabilitation at 2:26 PM and waffle boots were placed on the patient at 2:57PM to the right and left heel by the rehabilitation department. According to documentation in the medical record, at 2:57 PM the right heel had a stage one pressure area which measured 3.3 centimeters by 3.8 centimeters by zero and the left heel had a stage one pressure area which measured 1.6 centimeters by 1.8 centimeters by zero.

Further review of the medical record with Staff B revealed documented evidence from 11/06/11, at 7:52 PM until the patient was transferred to the rehabilitation department on 11/07/11, at 2:20 PM, Patient #9 was not turned and repositioned every two hours. The medical record contained documentation the patient was either in a supine position or stated the patient was resting in bed. The documentation lacked evidence the patient was turned and repositioned every two hours from 11/06/11 at 7:52 PM until transfer on 11/07/11 at 2:20 PM.

Review of the medical record the afternoon of 01/10/11, with Staff B stated both of the pressure areas to the patient's heels developed in house. Further review of the medical record with Staff B revealed at 9:40 AM on 11/7/11, a daily skin assessment was completed on patient #9 and there were no noted areas of pressure areas to the patient's bilateral heels until the patient was transferred upstairs to the rehabilitation unit.

This finding was verified with Staff B the afternoon of 01/10/12.