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Based on the degree and manner of deficiencies, the Facility failed to be in compliance with the Condition of Participation of Nursing. Specifically, the Facility failed to prevent, identify, and treat patient pressure ulcers.

The Facility failed to meet the following Standards under the Condition of Nursing:

Tag A 0386 Organization of Nursing Services- Conditions of Participation
The Facility failed to prevent, identify, and treat patient pressure ulcers.

Based on observations, interviews, and document review, the Facility failed to prevent, identify, and treat pressure ulcers.

This failure contributed to patients developing pressure ulcers that were not promptly identified and treated.

FINDINGS:
1. The Facility did not ensure that nursing staff prevented, identified, and treated pressure ulcers in 2 out of 6 (Sample Patients #1, #2, #5, #9, #15, #18) patients sampled with documented pressure ulcers.

a) On 04/17/13 through 04/19/13, a sample of 6 (Sample Patients #1, #2, #5, #9, #15, #18) patient medical records with documented pressure ulcers was completed. The sampled medical records revealed that 2 out of 6 sampled patients (Sample Patient #15 and #18) were admitted to the facility with no documented pressure ulcers. The facility's Wound Care Nurse (WCN) reviewed the medical records of Sample Patient #15 and #18 and verified that the admission assessments for these patients did not contain documentation of pressure ulcers.

b) On 04/18/13, Sample Patient #15's medical record was reviewed. Sample Patient #15 was admitted to the Facility on 07/25/12 and had an initial skin assessment performed by a registered nurse at 8:00 p.m. on 07/25/12. The registered nurse documented Sample Patient #15's skin as, "pink, warm, dry, smooth, well hydrated, intact." There was no documentation of a pressure ulcer upon admission. On 07/31/12 at 5:08 p.m., a staff nurse documented," Wound care consult completed", but the medical record contained no documentation from the WCN.

The first documentation of a pressure ulcer by the facility's WCN was time-stamped as 08/24/12 but contained a typed statement that the WCN's assessment was performed on 08/20/12 at 12:00 p.m. During his/her first documented encounter with Sample Patient #15, the facility's WCN documented Sample Patient #15's pressure ulcer as 2 centimeters long, 1.4 centimeters wide, "community acquired," and "unstageable." The WCN verified these findings and stated that unstageable meant that s/he could not see the base of the wound as it was covered with sloughing or necrotic (dead) tissue. The WCN stated that community acquired meant that the pressure ulcer had been acquired prior to arriving at the facility. The WCN verified there had been no documentation in Sample Patient #15's medical record that stated the patient had a pressure ulcer upon admission to the facility.

c) On 04/17/13 at 2:30 p.m., a review of Sample Patient #18's medical record was conducted with the facility's WCN. Sample Patient #18 was admitted to the Facility on 08/30/12 and had a skin assessment performed by a registered nurse upon admission. The registered nurse documented the patient's initial skin assessment as,"pink, warm, dry, smooth, well hydrated, intact." There was no documentation of a pressure ulcer upon admission.

On 09/06/12 at 8:18 a.m., a staff nurse documented," Stage 1 sacral wound cleaned and Mepilex applied. Will notify wound care RN." The WCN stated that s/he had ordered a pressure relieving mattress for Sample Patient #18 on 09/06/12, but could not find any documentation of having assessed the patient. On 09/18/12 at 7:21 p.m., a staff nurse documented a 2.5 centimeter long by 1.2 centimeter wide pressure ulcer to the patient's coccyx, but the medical record contained no documentation of an assessment by the WCN.

The WCN verified the first WCN assessment for Sample Patient #18 was documented on 09/21/12 at 12:52 p.m., and documented the patient's pressure ulcer as 2 centimeters long, 1.5 centimeters wide, "unstageable," and "community acquired." The WCN could not find any documentation of a wound assessment by the WCN prior to 09/21/12. The Facility's WCN stated the documentation regarding Sample Patient #18's pressure ulcer being, "community acquired," was incorrect and that Sample Patient #18, "got the pressure ulcer here and it should have been documented as hospital acquired ".

2. The Facility did not provide consistent documentation of patient's skin assessment and pressure ulcers.

a) On 04/17/13, a review of Sample Patient #18's medical record was conducted with the facility's Wound Care Nurse (WCN) and the patient's skin assessments were reviewed. On 09/18/12 at 7:21 p.m., a staff nurse documented the patient's skin assessment as, "intact," but documented a 2.5 centimeter long by 1.2 centimeter wide pressure ulcer to the patient's coccyx. On 09/20/12 at 1:18 a.m., the staff nurse documented the patient's skin as, "not intact" and documented a pressure ulcer to the patient's coccyx. On 09/20/12 at 8:04 a.m., the staff nurse documented the patient's skin assessment as,"intact" and entered no documentation of the patient's pressure ulcer. On 09/21/12 at 9:07 p.m., the staff nurse documented the patient's skin as "intact," but documented a pressure ulcer to the patient's coccyx. On 09/21/12 at 12:52 p.m., the WCN documented the patient's pressure ulcer as 2 centimeters long, 1.5 centimeters wide, and "unstageable." The Facility's WCN stated the documentation by nursing staff was not consistent.

b) On 04/18/13, a review of Sample Patient #15's medical record was conducted. Sample Patient #15's pressure ulcer was assessed by the Wound Care Nurse on 08/20/12 and was documented as "unstageable" and 2 centimeters long and 1.4 centimeters wide. The staff nursing notes from 08/20/12 at 8:27 p.m. documented Sample Patient #15's skin as, " dry, smooth, well hydrated, intact," and made no mention of the pressure ulcer. The Facility's WCN verified these findings.

3. The Facility failed to provide prompt assessment of the patient's pressure ulcers.

a) On 04/17/13, Sample Patient #18's medical record was reviewed with the Facility's Wound Care Nurse (WCN). Sample Patient #18's medical record revealed that on 09/06/12 at 8:18 a.m., a staff nurse documented," Stage 1 sacral wound cleaned and Mepilex applied. Will notify wound care registered nurse." The WCN stated s/he had ordered a pressure relieving mattress for the patient on 09/06/12, but was unable to find any documentation that s/he had assessed the patient.

The first documentation of an assessment by a WCN was documented as 09/21/12 at 12:52 p.m., in which the WCN documented the patient's pressure ulcer as "unstageable". The WCN verified these findings.

b) On 04/18/13, Sample Patient #15's medical record was reviewed. The medical record revealed the patient's staff nurse requested a wound care consult from the facility's WCN on 07/31/12 at 5:08 p.m. The first documentation of an assessment of Sample Patient #15's "pressure ulcer" by the WCN was documented on 08/20/12 at 12:00 p.m. The WCN verified these findings.

c) On 04/18/13 at 10:00 a.m., the facility's policy, "Wound Care Treatment" was reviewed. The policy stated," Wound Care Coordinator/Designee: Provides Consultation and assessment within 72 hours on all patient with pressure ulcers: Stage II, III, IV, unstageable or DTI (deep tissue injury), infected or dehisced surgical wounds, partial or full thickness burns, arterial/venous insufficiency ulcers, and atypical wounds. Documentation also includes measurement and photographing of wounds." The Facility's Director of Quality (DQM) and Wound Care Nurse (WCN) both verified this was the current policy.

4. The Facility did not provide consistent assessment of the patient's pressure ulcers.

a) On 04/17/13 at 2:30 p.m., a review of Sample Patient #18's medical record was conducted with the Facility's Wound Care Nurse (WCN). Patient #18's medical record documented a WCN as having assessed the patient's sacral (coccyx) wound on 09/21/12, 09/26/12, 10/01/12, 10/12/12, and 10/15/12. The WCN verified this was inconsistent with facility policy.

b) On 04/18/13, a review of Sample Patient #15's medical record was completed. Sample Patient #15's medical record documented a WCN as having assessed the patient's sacral (coccyx) wound on 08/20/12, 09/06/12, 09/19/12, 09/28/12, and 10/01/12. The WCN stated it was facility policy that a WCN would assess and document on all wounds every 7 days. The WCN acknowledged this had not been done consistently.

c) On 04/18/13, the Facility's policy, "Wound Care Treatment" was reviewed. The policy stated,"The Wound Care Coordinator/Designee: 2. Conduct focused reassessment of all patients or designate when necessary; and measure all wounds within each weekly period, per policy, with appropriate documentation." The Facility's WCN and Director of Quality Management (DQM) verified this was the current policy.

5. The Facility did not ensure its staff could find wound care orders or wound care documentation in the facility's charting system.
a) On 4/17/13 at 3:30 p.m., an interview was conducted with Staff Nurse #1. Staff Nurse #1 was unable to locate Sample Patient #9's wound care orders. The facility's Director of Nursing (DON) attempted to assist Staff Nurse #1 in locating the wound care orders for Sample Patient #9, but was unable to locate them.

The facility's Wound Care Nurse (WCN) then assisted Staff Nurse #1 in locating the wound care orders for Sample Patient #9 and discovered the orders had expired five days prior to the survey. The WCN and Staff Nurse #1 stated they were both unaware these orders had expired, but that Sample Patient #9 was still receiving wound care.

Staff Nurse #1 was unable to verbalize how s/he would know the patient was receiving his/her ordered wound care if s/he could not find the order.

b) On 04/18/13 at 2:00 p.m., an interview was conducted with Staff Nurse #2 in the facility's Monitored Observation Unit (MOU). Staff Nurse #2 was asked to show the surveyors the pressure ulcer staging tool the WCN stated was available on the facility's Electronic Medical Record (EMR). Staff Nurse #2 was unable to locate the area of the patient's EMR where s/he could reference pressure ulcer staging tool.

c) On 04/18/13 at 3:45 p.m., an interview was conducted with Staff Nurse #3. Staff Nurse #3 was unable to locate documentation from the Wound Care Nurse (WCN) or any other documentation regarding the dimensions of the wound. Staff Nurse #3 was unable to verbalize how s/he would know if the patient's wound had improved without being able to look at the dimensions noted in the WCN's documentation.

6. The Facility did not address patient pressure ulcers during daily morning nursing staff meetings regarding patient care.

a) On 04/17/13 at 1:30 p.m., an interview was conducted with the Facility's Director of Quality Management (DQM). The DQM stated that nursing staff held a daily morning meeting that addressed a variety of nursing issues related to the patients on the unit. The DQM stated that pressure ulcers were not routinely discussed at these meetings.

b) On 04/17/13 at 2:30 p.m., the Facility's internal documents for daily morning nursing meetings were reviewed. The document did not contain any information regarding pressure ulcers for patients on the unit.

7. The Facility did not ensure its staff documented patient pressure ulcers in the facility's internal incident report logs.

a) On 04/17/13 at 1:30 p.m., and interview was conducted with the Facility's Director of Quality Management (DQM). The DQM stated the facility's incident log was used to record data regarding pressure ulcers that was reported up to quality. The DQM reviewed the facility's incident logs from 07/2012 to 02/2013 and stated there was no documentation of pressure ulcers on the incident log. The DQM was unable to state how information regarding pressure ulcers could be used in quality if the data was not accurately recorded in the incident logs.

b) On 04/17/13 at 2:30 p.m., an interview was conducted with the facility's Wound Care Nurse (WCN). The WCN stated that it was policy that nursing staff would complete an incident report on all patients who developed pressure ulcers while admitted to the Facility.

c) On 04/18/13, a review of the Facility's incident log revealed that neither Sample Patient #15 or Sample Patient #18 were not documented in the facility's incident logs as having developed pressure ulcers while at the Facility.

d) On 04/18/13 at 10:00 a.m., the Facility's policy, "Patient Safety/Risk Management" was reviewed. The policy listed events that should be reported and recorded on the facility's incident log. The policy listed pressure ulcers and pressure wounds as "Level 3 events," which the facility defined as, "occurrences or situations resulting in actual or potential permanent lessening of bodily function not related to the natural course of the patient's illness or underlying condition." The Facility's DQM verified this was the current policy.