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Based on record review and interview the facility failed to ensure nursing staff notified a physician of a change in patient condition in a timely manner. Citing 1 of 5 patient medical records reviewed. ( Patient #1)

Findings include:
Review of patient medical records on 4/16/2014 at 1:00 pm in the facility conference room revealed the following:
1. Review of medical record for patient #1- Daily Assessment, Patient Rounding, and Shift Physical Assessment dated 3/19/2014 thru patient discharge on 3/30/2014 at 12:31 pm revealed the following:
All patient care documentation complete including documentation of patient status, vital signs, skin assessment, pain assessment, intake and output, gastrointestinal assessment, genitourinary assessment, comfort measures, and psychosocial assessments.
Documentation concerning the scrotal skin breakdown:
"3/20/2014 at 8:29 am revealed- Reproductive Assessment: testicle location- bilateral; scrotum appearance-swelling lesions; male reproductive comment: 2 areas on scrotum with breakdown. Patient has been previously very agitated and would not let staff touch him or move any part of his body.
Integumentary Assessment: patient with abdominal binder.
Psychosocial Assessment: History of dementia.
3/21/2014 at 10:07 pm- Reproductive Assessment: Scrotum appearance- swelling lesions.
Male reproductive comment- 2 areas on scrotum with breakdown. Patient has been previously very agitated and would not let staff touch him or move any part of his body.
3/22/2014 at 3:05 am- Male reproductive assessment: scrotum appearance- swelling lesion. Male reproductive comment: 2 areas on scrotum with breakdown. Patient previously very agitated and would not let staff touch him or move any part of his body.
3/22/2014 at 5:25 am- Nurse rounding comment: Assisted patient with cleaning, changing diaper. Swelling/redness noted to scrotum. Dr. Torres making rounds. Ordered silver sulfadiazine 2 times daily for scrotum. Instructed to elevate on towel. Done, with family assistance. Integumentary note: Patient with abdominal binder. Patient has superficial skin tears to scrotum. Has been assessed per Dr. Torres.
3/22/2014 at 4:22 pm- Nurse Rounding comment: Patient had incontinent episode of urine. Patient bathed and complete linen changed x 2 assist. Family staying in room all the time. Family feeding patient breakfast slowly. Dr. Arfeen visited this am. Daughter state she wanted patient to remain in wrist restraints because he is so fast and pulls lines and tubes out. Daughter stated, patient has dementia and all questions should be addressed to family. Daughter stated, "We are his eyes and ears"."

Review of Christus Hospital Policy and Procedures revealed the following:
"Title: Braden Scale Use
Affected Departments: Nursing Administration
Purpose: To identify patients at risk for pressure ulcer formation, document risk status, and to institute nursing measures to prevent pressure ulcers from occurring.
Policy: The Braden Scale will be completed on all patients age 5 and above on admission and every 24 hours on the day shift.
Procedure:
Staff Level: RN, LVN
1. Screen the patient for risk of pressure ulcer formation using the Braden Scale:
A. On admission to the hospital (Must be an RN)
B. Repeat when there is any change in patient condition.
C. The Braden Scale will be repeated every 24 hours on the day shift. The LVN will gather data and report any changes in the scale to the RN.
D. Add the patient's total score.
E. Record the Braden Scale Score in the medical record.
2. The RN is responsible for instituting the appropriate nursing interventions, including:
A. Referral for Braden Score of 12 or less to WPCN (Wound, Ostomy Continence Nurse) when appropriate.
B. Referral to PT/OT if consistent with overall goals of care and the potential exists for improving individual's mobility and activity status.
C. Referral to Dietician if Nutrition subscale equals 1 or 2."

Review of the Christus Hospital "Skin Integrity Program" guidelines on 4/27/2014 revealed the following:
"Purpose: Provide for assessment, staging, interventions and documentation of patients with actual or potential skin breakdown.
Assessment and Documentation:
? All patients should be assessed for pressure ulcer risk using a nationally recognized risk assessment scale (Braden). This should be documented on admission and daily by a registered nurse in the nursing documentation tool.
? The initial assessment should be completed within eight (8) hours of admission and completed by an RN. Assessment should be head to toe after removing any dressing, anti-embolism stockings, boots, and other adjunctive devices unless medically contra-indicated and recorded in the nurses notes. The initial assessment creates a baseline for further skin and/or wound care.
? Risk assessment should be performed on admission, at time of transfer to another unit, and if change of condition occurs. Braden scale should be performed every 24 hours during the morning shift or whenever the patient's condition changes or deteriorates. The care plan should be modified to reflect any changes of the patient's risk factors.
? All patients should have wound measured using photography and a recognized available measurement system such as EZ graph, and/or wound rulers. Measurements should be completed on admission, every 7 days and on discharge.
? This documentation is part of the permanent medical record.
Nutritional Therapy
? Nutritional status is assessed on admission and patient is referred based on needs.
Facility Based Skin Care Committee and Wound Care Team
? Each CHRISTUS facility should develop and implement a facility based skin care committee and wound care team with ongoing documentation of meting and actions taken."

Interview with staff #14 on 4/16/2015 at 3:00 pm confirmed the findings.