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Based on medical record review, staff interview and policy review, the facility failed to ensure that a Registered Nurse (RN) evaluated Patient #1 on an ongoing basis to ensure Patient #1's pressure ulcer assessments included: risks for developing pressure ulcers; location, stage, length, width, and depth of pressure ulcer; wound color; presence or absence of odor; presence or absence of drainage; amount of drainage; type of drainage; and description of the skin surrounding the wound.


Findings include:


Record review revealed that Patient #1 was a 78 year old who was admitted to the facility on 01/04/14 with complaints of chest pain and shortness of breath. At that time the patient was ambulatory and did not have a pressure ulcer.


Review of physician's progress notes revealed:
"01/08/2014 Patient remains with an open chest, intra-aortic balloon pump placed through the ascending aorta and emanating from the chest. An attempt to close her chest yesterday was unsuccessful due to her anasarca. (Doctor) is attempting to effectively diurese her in order to take her back and attempt closure in the next couple of days. The patient's heart was essentially visible with open chest with open retractors and hemostats in place. Mediastinal pleural chest tubes are also present, as well as pacer wires. Status post coronary artery bypasses grafting, postoperative day number three (3). Patient remains intubated and sedated with her chest open, balloon pump have been removed."
"01/15/14 The patient is status post coronary artery bypass surgery. She is currently sedated on ventilator support. She had a blood transfusion also and she has an aortic balloon pump in place. Patient now is in the intensive care unit (ICU). She is on sedation."


At the time of admission the patient was ambulatory and had no documented evidence of any pressure ulcers. There was no documented evidence that the patient was assessed for developing pressure ulcers. Documented assessments did not include risk for developing pressure ulcers; number; exact locations; stage, length, width, and depth; location, wound color, presence or absence of odor and drainage; amount of drainage, type of drainage; wound tunneling/undermining; description of skin surrounding pressure ulcer.


A skin assessment dated 01/15/14 noted that the patient had a blister on the back; Stage II pressure ulcer to the buttock; a blister to top of the left foot; a bruise to the left heel; a blister to the top of the right foot and inner thigh; and redness to the right heel. On 01/15/14 the physical therapist recommended contracture boots and floating the patient's heels. A nursing assessment on 01/15/14 indicated that the recommendation was followed.


Review of skin assessments revealed:
On 01/16/14 a Stage II pressure ulcer and blisters to the left sacrum and right lower extremity were noted.
On 01/17/14 at 10:50 a.m. erupted blister/skin tear to left buttock; blisters and eroded areas to tops of both feet were noted.
On 01/17/14 at 9:50 p.m. a large wound on sacral area, scabbed over and broken skin; a large blister over top of foot; and blister over top of right foot were noted.
On 01/18/14 redness and eschar on buttock were noted.
On 01/19/14 eschar to sacral area; wound on top of left foot, looks like previous blister that popped; unstagable wound to buttocks, black eschar noted on left buttock, Stage II to right buttock; bilateral blisters to top of feet;
On 01/20/14 at 8:27 a.m. noted Stage II on right buttock site about the size of half dollar with dark eschar tissue on left side.
On 01/20/14 at 3:18 p.m. noted large scab to inner upper left arm; black eschar to left buttock; Stage II to right buttock; blisters to bilateral ankles; blister to bilateral top left leg.
On 01/23/14 a large pressure to the sacrum/buttocks; blisters to the right lower extremity; Stage II on the right buttocks; and an unstagable wound on the left buttocks were noted.
The patient was discharged home on 01/24/14.


Review of a wound consult dated 01/20/14 revealed, "We are consulted because of the presence of sacral buttock decubitus as well as blisters on the lower extremities around the ankle and feet, probably related to her congestive heart failure. Brief examination is first directed to the buttocks where a large area of black discoloration that is shallow and fairly firm on the left medical buttock representing an area measuring 4 x 5 cm (centimeter) of deep tissue injury. There are other shallow excoriations across the medial side of the right buttock. Further examination is directed to the lower extremities where several shallow blisters are noted on both lower extremities as well as the heels representing stage 1 and 2 peripheral decubitus."


Review of the facility's "Protocol for Prevention and/or Treatment of Pressure Ulcers" (effective date January 1999) revealed, "Purpose: To establish guidelines to be followed when a patient is identified with moderate or high potential for skin problems through the Needs Assessment Screening Tool. The Prevention Protocol contained the following requirements. Heel placed protectors/devices that raise the heels off the bed should be placed under the heels of individual."


Review of the facility's "Guidelines For Preventing Wound Care and Documenting On The Wound Care" (effective date July 1998) revealed:

"1. A Wound Care Flowsheet should be placed in the interdisciplinary section of the chart for each being treated, eg, hematoma, surgical would, pressure ulcer, ECT. Complete a form for each wound. Write the location of the wound at top of each page so that the correct wound is being documented.

2. A. Place a patient identification sticker on each page of the Wound Care Flowsheet.
B. Write the location of the wound in the blank and place an X on figure to note location of wound.
C. Write date and time of assessment.
D. Write corresponding # of type wound/problem that is being treated/assessed.
E. If wound is pressure ulcer partial thickness-number 1- (intra-dermis, but not
through)
Or full thickness-number 2 (dermis to SC tissue or muscle) or N/A-number 3.
F. If Pressure ulcer - Mark stage as defined in upper right corner of form. If wound bed is covered with eschar or slough the wound cannot be correctly staged. It should be marked UTD.
G. Wound should be measured in cm weekly and prn. Length = longest points. Width = widest points. Depth = deepest point in would bed. Use sterile cotton-tipped applicator to measure depth.
H. Mark whether there is tunneling or undermining of wound, and maximum amount in cm in location based on clock.
I. If wound bed is 100% of one color, mark only that #. If more than one, Mark #5, then % of each."

Findings were discussed during interview with the Director of Safety and Risk Management on 9/30/14 from 1:40 p.m. to 2:55 p.m. During this time she reviewed the patient's medical record. No additional information was provided.