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Based on record review and interview the hospital failed to provide care in a safe setting for 2 of 10 patients (Patient #2 and #8) in that

1) Patient #2 acquired a pressure ulcer within 48 hours of admission and treatment orders were not received until nine days later, and

2) Patient #8 acquired a pressure ulcer to his lower back and skin excoriation in his groin within four days of hospitalization.


Findings included:
Patient #2 was admitted on 10/28/12 at 14:05 to the hospital Emergency Department (ED) with Coughing and Breathing Problems.

Emergency Department (ED) Nurses Notes dated 10/28/12 at 14:40 noted Patient #2 had dry skin.

The History and Physical documentation dated 10/28/12 at 22:15 noted Patient #2's past medical history included Diabetes Mellitus, Seizure Disorder, and Mental Retardation, and noted the patient was "fragile." Admitting diagnoses included Aspiration Pneumonia and Sepsis (severe body response to bacteria or other germs).

Emergency Department (ED) Nurses Notes dated 10/28/12 at 14:40 noted Patient #2 had dry skin. The Braden Scale For Predicting Pressure Sore Risk documentation dated 10/28/12 at 19:48 noted "no apparent problem." The patient was assessed to be at " moderate risk " to develop a pressure ulcer.

Nursing skin documentation dated 10/30/12 at 19:30 noted Patient #2 had an "unstageable" pressure ulcer to her coccyx. Nursing skin documentation dated 10/31/12 at 08:00 AM noted a "Stage II" pressure ulcer on Patient #2's coccyx.

Physician Orders dated 11/08/12 at 11:41 AM reflected orders for a wound care consult for Patient #2's pressure ulcer. Wound care orders dated 11/08/12 at 13:50 included an air mattress, medicated powder, and dressing change every two hours to treat a "stage II" pressure ulcer.

The hospital Coding Summary dated 11/30/13 at 14:52 reflected Patient #2 had a Stage II pressure ulcer which was "not present on admission."

Hospital Personnel #5 stated on 9/11/13 at 13:50 that Patient #2's skin was assessed in the ED to be "intact." Initial documentation of "redness" was two days after admission and the patient was discharged with a pressure ulcer.

The Hospital Pressure Ulcer Prevention and Intervention Policy dated 08/2012 stated as " ...responsibility of nursing and patient care providers to ...implement skin breakdown preventative strategies and Pressure Ulcer interventions and treatment as indicated ... "

2) Patient #8's ED Nurses Notes reflected the patient arrived on 09/07/13 at 20:04 and was hospital admitted with Pneumonia on 09/08/13 at 00:17 AM.

Wound skin flow sheets dated 09/08/13 at 03:00 AM, 09/08/13 at 07:46 AM, 09/09/13 at 08:33 AM, and 09/10/13 at 22:00 reflected Patient #8 had an abrasion to the left ankle. According to wound assessment flow sheets dated 09/11/13 at 13:27 and 09/12/13 at 00:32 AM Patient #8 had a "Stage II Decubitus/Pressure Ulcer" on his coccyx and also "excoriation on [his] groin [and] perirectal scrotum."

Physician Progress Notes dated 09/10/13 at 09:17 AM, 09/11/13 at 12:54, and 09/12/13 at 10:35 AM noted Patient #8's skin was "clear...no decubiti..."

Hospital Personnel #15 was interviewed on 09/12/13 at 11:50 AM and stated Patient #8's decubitus was not documented on admission but noted on the shift assessment on 09/11/13 at 06:00 AM.

Hospital Personnel #14 stated in an interview on 09/12/13 at 12:05 PM she had discovered Patient #8's pressure ulcer on 09/11/13.

Hospital Personnel #6 verified the above findings on 09/12/13 at 12:25 PM.

Based on record review and interview nursing staff failed to supervise and evaluate the nursing care for 2 of 10 patients (Patient #2 and #8) in that

1) Patient #2 acquired a pressure ulcer within 48 hours of admission and treatment orders were not received until nine days later, and

2) Patient #8 acquired a pressure ulcer to his lower back and skin excoriation in his groin within four days of hospitalization.


Findings included:
Patient #2 was admitted on 10/28/12 at 14:05 to the hospital Emergency Department (ED) with Coughing and Breathing Problems.

Emergency Department (ED) Nurses Notes dated 10/28/12 at 14:40 noted Patient #2 had dry skin.

The History and Physical documentation dated 10/28/12 at 22:15 noted Patient #2's past medical history included Diabetes Mellitus, Seizure Disorder, and Mental Retardation, and noted the patient was "fragile." Admitting diagnoses included Aspiration Pneumonia and Sepsis (severe body response to bacteria or other germs).

Emergency Department (ED) Nurses Notes dated 10/28/12 at 14:40 noted Patient #2 had dry skin. The Braden Scale For Predicting Pressure Sore Risk documentation dated 10/28/12 at 19:48 noted "no apparent problem." The patient was assessed to be at "moderate risk " to develop a pressure ulcer.

Nursing skin documentation dated 10/30/12 at 19:30 noted Patient #2 had an "unstageable" pressure ulcer to her coccyx. Nursing skin documentation dated 10/31/12 at 08:00 AM noted a "Stage II" pressure ulcer on Patient #2's coccyx.

Physician Orders dated 11/08/12 at 11:41 AM reflected orders for a wound care consult for Patient #2's pressure ulcer. Wound care orders dated 11/08/12 at 13:50 included an air mattress, medicated powder, and dressing change every two hours to treat a "stage II" pressure ulcer.

The hospital Coding Summary dated 11/30/13 at 14:52 reflected Patient #2 had a Stage II pressure ulcer which was "not present on admission."

Hospital Personnel #5 stated on 9/11/13 at 13:50 that Patient #2's skin was assessed in the ED to be "intact." Initial documentation of "redness" was two days after admission and the patient was discharged with a pressure ulcer.

The Hospital Pressure Ulcer Prevention and Intervention Policy dated 08/2012 stated as " ...responsibility of nursing and patient care providers to ...implement skin breakdown preventative strategies and Pressure Ulcer interventions and treatment as indicated ... "

2) Patient #8's ED Nurses Notes reflected the patient arrived on 09/07/13 at 20:04 and was hospital admitted with Pneumonia on 09/08/13 at 00:17 AM.

Wound skin flow sheets dated 09/08/13 at 03:00 AM, 09/08/13 at 07:46 AM, 09/09/13 at 08:33 AM, and 09/10/13 at 22:00 reflected Patient #8 had an abrasion to the left ankle. According to wound assessment flow sheets dated 09/11/13 at 13:27 and 09/12/13 at 00:32 AM Patient #8 had a "Stage II Decubitus/Pressure Ulcer" on his coccyx and also "excoriation on [his] groin [and] perirectal scrotum."

Physician Progress Notes dated 09/10/13 at 09:17 AM, 09/11/13 at 12:54, and 09/12/13 at 10:35 AM noted Patient #8's skin was "clear...no decubiti..."

Hospital Personnel #15 was interviewed on 09/12/13 at 11:50 AM and stated Patient #8's decubitus was not documented on admission but noted on the shift assessment on 09/11/13 at 06:00 AM.

Hospital Personnel #14 stated in an interview on 09/12/13 at 12:05 PM she had discovered Patient #8's pressure ulcer on 09/11/13.

Hospital Personnel #6 verified the above findings on 09/12/13 at 12:25 PM.