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Based on document review and interview the facility nursing staff failed to accurately evaluate and intervene in the care of 1 of 1 patient's identified.

On 11/19/2012 in the conference room the medical record (MR) for Patient #1 was reviewed and revealed the following: .On 7/15/2012 at 1028 hrs Pt #1 was admitted via the Emergency Department (ED) to the Intensive Care Unit (ICU) with Acute Respiratory failure, septic shock, Diabetic Ketoacidosis, Diabetes Mellitus type 2, uncontrolled, Nausea, Vomiting, and Diarrhea, severe dehydration, elevated troponins likely secondary to metabolic injury to myocardium, severe metabolic acidosis secondary to a combination of septic shock and diabetic Ketoacidosis and acute renal failure.

Continued review revealed the following: Pt #1 was admitted to the Intensive Care Unit via the Emergency Department (ED) on 7/15/2012 at 1028. The nursing assessment documented 7/15/2012 at 1300 hours (hr) records the Integumentary assessment as follows: Integumentary symptoms none, skin moist, warm, dry, turgor is good, smooth and normal for ethnicity. The Braden scale, skin risk assessment, was documented as "high".

Continued review revealed nursing staff documented on 7/15/2012 at 1700 hr, Pt does not follow commands... is now spontaneously moving all four extremities with no purposeful movement. The integumentary assessment documented for 7/15/2012 at 1700 hr recorded no changes from the initial assessment. Pt #1 skin remained warm, dry, turgor is good, skin is smooth normal for ethnicity.

Further review revealed the integumentary assessment for 7/16/2012 at 0500 hr nurses documented "symptoms none, membranes moist, skin warm,dry, turgor good,skin smooth, normal for ethnicity. rt (right) and lt (left) arm bruised. rt and lt heel reddened due to pt constantly moving lover extremities on bed". Off loading pressure relief boots were ordered for Pt #1 and received 7/16/2012 however, damage to the tissue of both heels had already occurred.

The integumentary skin assessment from 7/16/2012 forward records bilateral reddened heels and on 7/23/2012 necrosis has begun and wound treatment orders of Mepilex was ordered to cover bilateral heals.

On 11/26/2012 an interview with Pt #1 revealed the following: Pt #1 reported she developed a wound in her head during her stay in the ICU. After speaking with Pt #1 husband and daughter, who initially found the wound, they described a reddened area on the back top portion of the head that was broken. Pt #1's husband and daughter also described a small break on the left ear that was bleeding when they reported it to the nurse. Mr. Walton also indicated his wife developed a small are of skin breakdown on her buttocks which healed.
A review of medical records found no nursing documentation of a head wound, an ear wound, or any skin irritation to her buttocks, however, review of nursing documentation did reveal Pt#1initially developed diarrhea with the addition of nutritional supplements, ordered via Nasogastric tube.

A review of medical records for Pt #1 stay in rehab, revealed 8/8/2012 staff # 6 documented patient with "Intact crust to back of head. No odor or drainage. Most likely pressure related she (pt #1) was in ICU. Dry crust covers wounds to both heels appears to be old ulcers due to the healing progression".

Further review of nursing documentation revealed on 7/16/2012 the nursing staff documented Pt #1 Left eye was swollen,edematous but the sclera was clear with no discharge. There is no change in the wording of the nursing documentation until 7/19/2012, when no assessment is recorded. The nursing assessment dated 7/21/2012 recorded Pt #1 eye as normal with no problems. Then 7/22/2012 the nurses documentation revealed Left eye swollen dryness, edematous, sclera reddened,discharge is clear. Right eye is tearing, redness, swollen conjunctiva is edematous sclera is reddened discharge is clear. There was no documentation the family was contacted regarding the symptoms the nursing staff observed. There was no documentation the physician was notified concerning the symptoms observed by nursing staff until a telephone order was transcribed on 7/26/2012, 2 days before Pt #1 was discharged and transferred to a University hospital in another state. The order was for Lacrilube ophthalmic ointment.

Based on chart review and interview the facility failed to identify the need to keep current the patient (Pt)care plan on 1 of 1 patients identified.

On 11/19/2012 a review of the Pressure ulcer Prevention and Management Protocol was reviewed and revealed the following definition: Page #2, G 3. Stage II: Partial thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed, without slough. Stage II may also present as a intact or open/ruptured, serum filled blister.

On 11/20/2012 a review of patient #1 medical record (MR) was reviewed and revealed the following. Pt #1 was admitted to the intensive care unit via the Emergency Department (ED) on 7/15/2012. Pt #1 was identified with bilateral red heels with blisters on 7/16/2012 at 2100 hours (hr).

Continuing to review the MR revealed the care plan implemented for Pt #1 did not include interventions for bilateral stage II heel wounds. Pt #1 nursing care plan recorded the following: Maintain intact skin.

Further review revealed on 7/23/2012 a physician's wound care order transcribed by staff # 8 which read, Mepilex AG (silver) to bilateral heel wounds every 5 days and as needed (PRN)

Continued review of Pt #1 nursing care plan revealed there was no treatment orders for pressure ulcer care. The physician's dressing order for Mepilex Ag was not found on the care plan. There were no nursing interventions addressing wound care.

An interview on 11/20/2012 with staff #1 confirmed there was no current care plan problem with interventions identified for skin break down in Patient #1 MR.

Further review of the patient's nursing care plan revealed there was no problem identified for an eye irritation that was initially documented in the nursing assessment on 7/16/2012. The symptoms of the eye irritation were not consistently addressed in the nursing documentation and when the symptoms worsened the symptoms were not identified on the nursing care plan and no nursing interventions were noted. Nursing documentation revealed the family was not notified and the physician was not notified until 7/26/2012. Pt #1 eye irritation had been identified and observed for 10 days before documentation indicated a physician was notified.