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Based on interview, record review and review of the facility's policies it was determined the facility failed to ensure their nursing staff developed and updated the plan of care and the facility failed to ensure that skilled nursing services were provided per the facility's skin breakdown policy and the plan of care policy.

Patient #1 entered the facility with no skin breakdown, however, the facility's failure to follow their policies related to skin breakdown prevention and the facility's failure to ensure their nursing staff developed and kept current a nursing care plan and the facility's failure to ensure skilled nursing services were provided resulted in Patient #1 developing pressure ulcers which required two (2) nine point two inch by nine point two inch (9.2"x 9.2") sacral borders to cover it.


Patient #10 entered the facility with skin breakdown on the right great toe, the right fifth toe, coccyx and the left buttock. The facility's failure to follow their policies related to skin breakdown, the facility's failure to ensure their nursing staff developed, and kept current, a nursing care plan and the facility's failure to ensure skilled nursing services were provided resulted in the worsening of the patient's wounds.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure skilled nursing services were provided per the facility's policies and protocols, the facility failed to ensure nursing staff developed and kept current, a nursing plan of care and failed to ensure skilled nursing services were provided for two (2) of ten (10) sampled patients (Patient #1 and Patient #10).

Patient #1 entered the facility with no skin breakdown; however, the facility's failure to follow their policies and protocol related to skin breakdown prevention, the facility's failure to ensure their nursing staff developed, and kept current, a nursing plan of care and the facility's failure to ensure skilled nursing services were provided resulted in Patient #1 developing pressure ulcers which required two (2) nine point two inch by nine point two inch (9.2"x 9.2") sacral borders to cover them.

Patient #10 entered the facility with skin breakdown to the right great toe, the right fifth toe, coccyx and the right buttock. The facility's failure to follow their policies and protocol related to skin breakdown prevention/treatment, the facility's failure to ensure nursing staff developed, and kept current, a nursing plan of care and the facility's failure to ensure skilled nursing services were provided resulted in worsening of the coccyx and buttock wounds.

The findings include:

Review of the facility's policy entitled, "Provide and Maintain Skin Integrity" (effective April 2011) revealed the facility would utilize an interdisciplinary approach for early identification and reduction of decubitus risks and in the treatment of existing wounds. All consulting team members would communicate their plan for decubitus prevention, and/or treatment, on the plan of care. The Registered Nurse (RN) would complete and document a skin integrity screening upon admission. Using the Norton Risk Assessment tool, the RN would perform a reassessment of risk factors on each inpatient every shift or with any significant change in the patient's condition. Head to toe skin assessments were to be completed and documented every shift. Based on the data obtained from the screening, a patient was determined to be at risk with one of the following: the patient was seventy-five (75) years old or older, a serum albumin of less than or equal to 2.5 g/dl, if the patient had an existing pressure wound, if bed-bound and/or chair-bound, or a Norton score of fourteen (14) or less (a Norton score of twelve (12) or less indicates high risk). Patients at risk for skin breakdown were to be repositioned in bed every two hours, if chair-bound reposition every hour and document turning schedule in the medical record. If actual alteration in skin integrity, the nurse would visually inspect, assess and document the area of altered skin integrity. The wound/ostomy nurse would be consulted. The wound location, measurements, drainage (type and amount), tissue in wound bed, wound edges and treatment performed/dressing that was applied were to be documented in the medical record.

Review of the facility's policy entitled, "Plan of Care" (effective March 2006), revealed all patients admitted to the facility would have a plan of care, to be initiated, by the RN within twenty-four (24) hours of admission and reviewed by the interdisciplinary team comprised of those involved in the care of the patient. Members of the interdisciplinary team would communicate through the plan of care and one (1) to one (1) as needed according to any changes in the patient's needs or condition. Further review of the policy revealed the plan of care would be reviewed and updated every twenty-four (24) by an RN; however, all members of the team were to make changes to the plan of care as required by the patient's condition and communicate those changes to the RN.

Review of the facility's policy entitled, "Management of Inpatient Transfers and Hand-Off Communication" (effective 11/15/07) revealed the Intrafacility Transfer Report Sheet was utilized to provide documentation of the communication and report process occurring during the transfer of patient care. It was the policy of the facility that clinicians would, when handing off patients, provide standardized information. Information communicated would allow clinicians the opportunity to ask and respond to questions to ensure patient safety. Continuity of care would be maintained through utilization of appropriate assessment, transporting personnel and required assistive equipment. Further review revealed the receiving nurse initiates the form when the transferring nurse initiates verbal report. All sections of the form were to be completed, document N/A or none if section not applicable. Document any significant past medical/surgical history, abnormal physical findings, wound care, pain scale, equipment needed, special needs, fall level, mobility status. A hand off of communication was to ensure pertinent information necessary for the safe and continuous care of the patient occurs throughout the clinical treatment of the patient.

1. Review of the clinical record revealed the facility admitted Patient #1, on 04/03/12, with diagnoses which included Diabetes, Bilateral Above Knee Amputations (BAKA), End Stage Renal Disease (ESRD), History of Cerebral Vascular Accident (CVA), Anemia, Arteriovenous (AV) Fistula Occlusion (came to hospital for outpatient clot removal), Peripheral Vascular Disease (PVD), Congestive Heart Failure (CHF) and Atrial Fibrillation (A Fib).

Review of Patient #1's admission assessment, dated 04/03/12 revealed an admission skin assessment was not performed. Further review of the admission assessment revealed no skin breakdown was noted. Further record review revealed Patient #1's nursing plan of care did not address the risk of skin integrity impairment.

Interview with Registered Nurse (RN) #1, on 05/04/12, at 9:23 AM, revealed she recalled taking care of Patient #1. She stated did not get to complete the initial skin assessment, did not get to do a full assessment because she was so busy. She stated she had to obtain orders from the Physician because there were no orders when Patient #1 arrived from the Vascular Lab. She stated she reported the lab results to the Physician, obtained orders for consults, ordered the patient a meal tray, educated the patient regarding fluid restrictions and got the patient ready for dialysis. She stated she was the admitting nurse and it was her responsibility to perform the initial skin assessment and develop the plan of care. She further stated the system failed because she did not complete the initial skin assessment and her documentation was not adequate.

Interview, on 05/02/12 at 6:00 PM, with the Nurse Manager of the Heart and Vascular Intermediate Unit (HVIU) revealed the initial skin assessment was to be done during the admission and then every twelve (12) hours/shift. She stated Skin Integrity should have been on the plan of care within twenty-four (24) hours.

Interview, on 05/03/12 at 10:40 AM, with the Chief Nursing Officer revealed the nurse did not follow policy and that was unacceptable. Skin assessments were not done and documented upon admission, the nurse did not develop the plan of care with skin integrity addressed, did not document appropriately and didn't turn patient every two (2) hours. The nurse did not follow guidelines in the policy of what to do if the patient had a pressure ulcer or to prevent one.

Review of the turning and repositioning documentation, dated 04/04/12, revealed no documented evidence Patient #1 was turned/repositioned from 4:00 PM until 2:00 AM on 04/05/12. According to the Nurses Notes dated 04/04/12, the patient was off the floor, for procedure, from 3:44 PM until 5:44 PM and from 5:44 PM until 11:46 PM for dialysis.

Interview, on 05/04/12 at 1:55 PM, with RN #3 revealed she was the nurse for Patient #1 on 04/04/12 at 4:00 PM through 7:00 PM. She stated the patient was in A Fib and she knew his/her fistula was clotting again, therefore, her main concern was his cardiac issue. Further interview revealed she was training another nurse that day and thought the other nurse would have turned him, however, she did not know if the trainee turned the patient.

Interview, on 05/04/12 at 2:31 PM, with RN #8 revealed she was the nurse for Patient #1 on 04/04/12 from 7:00 PM until 7:00 AM, however, the patient was at dialysis when she started her shift and didn't return to the floor until after 11:00 PM and was only on the floor for about an hour before being transferred to the Intensive Care Unit at approximately 1:00 AM.

Record review revealed on 04/05/12 the facility noted a quarter sized Stage II pressure wound to Patient #1's coccyx. The Wound Care Nurse was consulted on 04/05/12 and documented "There are Stage II wounds that are all pink with peeling skin noted". She further documented she suspected deep tissue injury. There was no documented evidence the wounds were measured. Interview with the Wound Care Nurse, on 05/04/12 at 8:30 AM, revealed she measured wounds if larger than a dime, and Patient #1's wounds were less than a dime. Further interview revealed there were probably four (4) wounds, she stated she was more worried about the deep tissue areas, deep tissue injury is more serious than peeling skin, deep tissue injury can not be staged because the extent is unknown (cannot tell how deep it will be). The Wound Care Nurse stated she should have documented how many peeling areas there were but she was human and made a human error.

Continued interview, on 05/04/12 at 8:30 AM, with the Wound Care Nurse revealed she performed bedside assessments, measured open wounds, recommended wound care and obtain Physicians Orders for the wound care. She stated she did not perform head to toe assessments on Patient #1, the nurses specified what the Wound Care Nurse was to assess. Further interview revealed the Wound Care Nurse reviewed the documentation from her consult with Patient #1 and stated the patient had peeling skin, dark purple unblanchable areas (deep tissue injury). She recommended skin care policy, use sacral borders as prevention and sacral border to be peeled back every day to assess and to reconsult Wound Care Nurse if needed.

Review of the record revealed no documented evidence Patient #1's wounds were assessed or measured on 04/06/12.

Further review of documentation revealed on 04/08/12 Patient #1 was not turned from 4:00 PM until 7:00 PM and no wound measurements were obtained. Continued review of the clinical record revealed on 04/09/12, Patient #1 was not turned/repositioned from 12:00 PM until 7:00 PM and there was no documented evidence of measurements of the wounds on 04/09/12. Continued review of the clinical record revealed no documented evidence Patient #1 was turned/repositioned from 11:00 AM until 7:00 PM on 04/10/12 and no documented evidence of wound measurements on 04/10/12, however, the record did indicate Patient #1 was at dialysis at that time. Documentation on 4/11/12, revealed Patient #1 was not turned/repositioned from 7:45 AM until 11:00 AM and from 11:00 AM until 2:00 PM and there was no documented evidence of wound measurements.

Further record review revealed no documented evidence the patient was turned/repositioned from 7:00 AM until 1:20 PM on 04/12/12 and no wound measurements were documented. On 04/13/12, the patient was not turned/repositioned from 5:00 AM until 8:00 AM, again no evidence the wounds were measured.

Interview, on 05/04/12 at 6:00 PM, with the Nurse Manager of HVIU revealed Patient #1 should have been turned every two (2) hours and it was unacceptable, not normal and definitely not policy that he/she was not turned and repositioned and the wounds measured.

Interview, on 05/02/12 at 1:00 PM, with RN #2 revealed she was Patient #1's nurse on 04/13/12, when she bathed him/her she noted a large open area to the coccyx and buttocks she stated, she had a problem placing sacral borders to cover the entire wound and thought she had to use two (2) sacral borders (which were 9.2 inches by 9.2 inches each) but could not remember if she charted it. Further interview revealed wounds were to be measured at admission and with every dressing change; however, she failed to measure the wounds on 04/13/12 as per the facility's policy.

Interview, on 05/03/12 at 10:40 AM, with the Chief Nursing Officer revealed the nurses were clearly not following policy and that was unacceptable. Skin assessments were not done and documented upon admission. The nurses did not document and measure wounds, did not develop a plan of care with skin integrity addressed, did not document appropriately, did not turn the patient every two (2) hours and did not follow up with the Wound Care Nurse. The Wound Care Nurse did not document appropriately. Basically, the nurses were not following all guidelines in the policy of what to do if the patient had a pressure ulcer or to prevent one.

Further record review revealed Patient #1 was transferred to dialysis on 04/04/12, 04/08/12, 04/10/12, 04/12/12 and the Cath Lab on 04/04/12. Three incomplete Intrafacility Transfer Reports, which were dated 04/08/12, 04/10/12 and one (1) undated report, were in the record. There was no documented evidence the patient was turned/repositioned every two hours during the dialysis treatments or in the cath lab.

Interview on 05/04/12 at 3:36 PM with the Accreditation and Regulatory Affairs Director revealed it was the nurses responsibility to ensure information was shared between units/departments. The nurse transferring the patient was responsible for giving report when the patient was leaving the unit and the nurse returning the patient was responsible for giving report to the floor nurse.

Interview, on 05/04/12 at 4:15 PM, with the Chief Nursing Officer (CNO) revealed none of the hand off sheets were completed correctly. She stated every department was supposed to follow policy regarding transferring patients and clearly that was not done. She also stated the care patients received on the floor did not meet requirements of policy and the incidents did not meet the facility's standard for providing patient care. She further stated ultimately she was responsible for ensuring it was done.

Interview, on 05/04/12 at 4:30 PM, with the Vice President of Quality revealed the Intrafacility Transfer Reports were not filled out properly and that was not acceptable and the nurses did not meet requirements of the policy. She further stated the care patients received and quality of care provided did not meet the standards of the facility.

2. Review of the clinical record revealed the facility admitted Patient #10 on 04/21/12 with diagnoses which included Myocardial Infarction (MI- Heart attack), Diabetes, Coronary Artery Disease (CAD) and Renal Failure.

Review of the facility's Admission Skin Assessment revealed Patient #10 was admitted with wounds on his/her right great toe, right fifth (5th) toe (both toes were necrotic), coccyx and right buttock. The admitting nurse initiated a consult with the Wound Care Nurse; however, only ordered the Wound Care Nurse to assess the patient's toes and did not inform the Wound Care Nurse of the skin breakdown to the Patient #10's coccyx/buttock. Further record review revealed no documented evidence a plan of care was developed to address skin integrity.

Interview, on 05/04/12 at 10:07 AM, with RN #8 revealed she was the admitting nurse and she was responsible for the development of the initial plan of care. She stated she should have developed a plan of care for skin integrity. Further interview revealed she initiated the Wound Care Nurse consult; however she failed to inform her of the breakdown on the coccyx and buttock on the consult. She stated she knew she was supposed to document everything she did on her shift but sometimes things got busy and she forgot to document everything but she knew "if it's not documented, it's not done".

Interview, on 05/02/12 at 6:00 PM, with the Nurse Manager of the Heart and Vascular Intermediate Unit (HVIU) revealed Skin Integrity should have been on the plan of care within twenty-four (24) hours.

Further review of the clinical record revealed no documented evidence the nurses measured the wounds on 04/23/12, 04/24/12, 04/25/12, 04/26/12, 04/27/12, 04/28/12, 04/29/12 and 04/30/12.

Interview, on 05/04/12 at 10:07 AM, with RN #8 revealed she should have measured the wounds because wounds were supposed to be measured at admission and every dressing change.

Interview, on 05/02/12 at 1:00 PM, with Registered Nurse (RN) #2 revealed she was Patient #10's nurse on 05/01/12. Further interview revealed when she bathed the patient she noted the patient's bottom was excoriated. After bathing the patient, she applied antifungal cream and a sacral border (dressing to promote healing and prevent further breakdown).

Interview, on 05/03/12 at 10:40 AM, with the Chief Nursing Officer revealed the nurses were clearly not following policy and that was unacceptable. Skin assessments were not done and documented upon admission. The nurses did not document and measure wounds, did not develop a plan of care addressing skin integrity, did not document appropriately, did not turn patient every two (2) hours and did not follow up with Wound Care Nurse. The Wound Care Nurse did not document appropriately. Basically, the nurses were not following all guidelines in the policy of what to do if the patient has a pressure ulcer or to prevent one.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to implement the policy to ensure nursing staff developed, and kept current, a nursing plan of care and failed to ensure skilled nursing services were provided related to skin breakdown prevention for two (2) of ten (10) sampled patients (Patient #1 and Patient #10).

Patient #1 entered the facility with no skin breakdown; however, the facility's failure to ensure their nursing staff developed, and kept current, a nursing plan of care, the facility's failure to ensure skilled nursing services were provided and the facility's failure to follow their policies and protocol related to the development of a plan of care related skin breakdown prevention resulted in Patient #1 developing pressure ulcers.

Patient #10 entered the facility with skin breakdown to the right great toe, the right fifth toe, coccyx and the right buttock. The facility's failure to ensure their nursing staff developed, and kept current, a nursing plan of care, the facility's failure to ensure skilled nursing services were provided and the facility's failure to follow their policies and protocol related to the development of a plan of care related to skin breakdown prevention/treatment resulted in worsening of the coccyx and buttock wounds.

The findings include:

Review of the facility's policy entitled, "Plan of Care" (effective March 2006), revealed all patients admitted to the facility would have a plan of care, to be initiated, by the RN within twenty-four (24) hours of admission and reviewed by the interdisciplinary team comprised of those involved in the care of the patient. Members of the interdisciplinary team would communicate through the plan of care and one (1) to one (1) as needed according to any changes in the patient's needs or condition. Further review of the policy revealed the plan of care would be reviewed and updated every twenty-four (24) by a RN, however, all members of the team were to make changes to the plan of care as required by the patient's condition and communicate those changes to the RN.

Review of the facility's policy, Provide and Maintain Skin Integrity (effective April 2011) revealed the facility would utilize an interdisciplinary approach for early identification and reduction of decubitus risks and in the treatment of existing wounds. All consulting team members would communicate their plan for decubitus prevention, and/or treatment, on the plan of care. The Registered Nurse (RN) would complete and document a skin integrity screening upon admission. Using the Norton Risk Assessment tool the RN would perform a reassessment of risk factors on each inpatient every shift or with any significant change in the patient's condition. Head to toe skin assessments were to be completed and documented every shift. Based on the data obtained from the screening, a patient was determined to be at risk with one of the following: the patient was seventy-five (75) years old or older, a serum albumin of less than or equal to 2.5 g/dl, if the patient had an existing pressure wound, if bed-bound and/or chair-bound, or a Norton score of fourteen (14) or less (a Norton score of twelve (12) or less indicates high risk). Patients at risk for skin breakdown were to be repositioned in bed every two hours, if chair-bound reposition every hour and document turning schedule in the medical record. If actual alteration in skin integrity, the nurse would visually inspect, assess and document the area of altered skin integrity. The wound/ostomy nurse would be consulted. The wound location, measurements, drainage (type and amount), tissue in wound bed, wound edges and treatment performed/dressing that was applied were to be documented in the medical record.

1. Review of the clinical record revealed the facility admitted Patient #1, on 04/03/12, with diagnoses which included Diabetes, Bilateral Above Knee Amputations (BAKA), End Stage Renal Disease (ESRD), History of Cerebral Vascular Accident (CVA), Anemia, Arteriovenous (AV) Fistula Occlusion (came to hospital for outpatient clot removal), Peripheral Vascular Disease (PVD), Congestive Heart Failure (CHF) and Atrial Fibrillation (A Fib).

Review of Patient #1's record revealed no documented evidence a skin assessment was performed during the admission assessment on 04/03/12. Further review of the admission assessment revealed no skin breakdown was noted. Further record review revealed Patient #1's nursing plan of care did not address the risk of skin integrity impairment even though the patient was bed-bound, obese and a Diabetic.

Interview with Registered Nurse (RN) #1, on 05/04/12, at 9:23 AM, revealed she was unable to perform the initial skin assessment because she was so busy and she also did not address skin integrity in the plan of care. She stated she was the admitting nurse and it was her responsibility to perform the initial skin assessment and develop the plan of care.

Interview, on 05/02/12 at 1:00 PM, with RN #2 revealed Patient #1 should have been care planned for skin integrity because he was supposed to be turned every two (2) hours, he required maximum assistance, he was obese and bed-bound.

Interview, on 05/02/12 at 6:00 PM, with the Nurse Manager of the Heart and Vascular Intermediate Unit (HVIU) revealed skin integrity should have been on the plan of care within twenty-four (24) hours.

Interview, on 05/03/12 at 10:40 AM, with the Chief Nursing Officer revealed the nurse did not follow policy and that was unacceptable. Skin assessments were not done and documented upon admission, the nurse did not develop the plan of care with skin integrity addressed. The nurse did not follow guidelines in the policy of what to do if the patient had a pressure ulcer or to prevent one.

Record review revealed on 04/05/12 the facility noted a quarter sized Stage II pressure wound to Patient #1's coccyx. The Wound Care Nurse was consulted on 04/05/12 and documented "There are Stage II wounds that are all pink with peeling skin noted". She further documented she suspected deep tissue injury. There was no documented evidence the wounds were measured and no documented evidence the facility developed or implemented a plan of care to address skin integrity.

Interview, on 05/02/12 at 1:00 PM, with RN #2 revealed she was Patient #1's nurse on 04/13/12, and noted when she gave the patient a bath, the skin was a large open area to the coccyx and buttock. She stated she had a problem placing sacral borders to cover the entire wound and thought she had to use two (2) sacral borders (which were 9.2 inches by 9.2 inches each) but could not remember if she charted it.

Continued review of the record revealed no documented evidence the facility developed or implemented a plan of care to address the actual skin breakdown for Patient #1.

2. Review of the clinical record revealed the facility admitted Patient #10 on 04/21/12 with diagnoses which included Myocardial Infarction (MI- Heart attack), Diabetes, Coronary Artery Disease (CAD) and Acute on Chronic Renal Failure.

Review of the facility's Admission Skin Assessment revealed Patient #10 was admitted with wounds on his/her right great toe, right fifth (5th) toe (both toes were necrotic), coccyx and right buttock.

Review of Patient #10's plan of care revealed skin integrity was not addressed until 04/30/12.

Review of the Physician's Orders revealed an order dated 04/21/12 for a Wound Care consult to assess the patient's toes; however there was no documented evidence the Wound Care Nurse was informed of the skin breakdown to the coccyx and right buttocks, and again no documented evidence of the development of a plan of care to address the patients' skin integrity.

Interview, on 05/04/12 at 10:07 AM, with RN #8 revealed she was the admitting nurse and she was responsible for the development of the initial plan of care. She stated she should have put skin integrity on the plan of care and didn't know why skin integrity was not on it. Further interview revealed she put in for the Wound Care consult, however she should have added the coccyx and buttock wounds on the consult.

Review of the Nurses Notes revealed the floor nurses assessed the wounds on 04/22/12, 04/23/12, 04/24/12, 04/25/12, 04/26/12, 04/27/12, 04/28/12 and 04/29/12 without addressing Skin Integrity on the plan of care.

Interview, on 05/02/12 at 1:00 PM, with Registered Nurse (RN) #2 revealed she was the patient's nurse on 05/01/12. She stated the plan of care should have included skin integrity due to Patient #10's age, decreased dietary intake and amputation.

Interview, on 05/02/12 at 6:00 PM, with the Nurse Manager of the Heart and Vascular Intermediate Unit (HVIU) revealed Skin Integrity should have been on the plan of care within twenty-four (24) hours.

Interview, on 05/03/12 at 10:40 AM, with the Chief Nursing Officer revealed the nurses did not develop a plan of care to address skin integrity and did not document appropriately. The nurses were clearly not following policy and that was unacceptable.