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Based on review of medical records and documents, observation, and staff interview, it was determined that the facility did not effectively ensure (a) that patients who are at risk for pressure ulcer development received proper care and interventions, and (b) staff complied with the protocol for treatment of patients at risk for pressure ulcer and those with skin breakdown. This deficiency was noted in one of six medical records (MRs) reviewed.

Findings Include:

Tour of the facility conducted on July 1, 2014 and July 2, 2014, followed by review of the medical record (MR) revealed:
A 69 year old female (MR #1) with a past history of HTN (hypertension - blood pressure in the arteries is elevated), DM (diabetes melitus - a disease characterized by high blood sugar), HLD (hyperlipidemia - abnormally elevated levels of any or all lipids and or lipoproteins in the blood), and multiple falls with fractures. She was admitted to the facility previously and underwent right (Rt) hip surgery on 3/11/14 for a Rt Intertrochanteric Fracture (a fracture below the neck of the right femur), and was discharged to a nursing home on 3/17/14 for inpatient rehabilitation.

On 04/03/14, at 09:14 AM, she was sent from the nursing home and presented to the ED with acute onset of Rt Hip pain and was readmitted to the facility for treatment of an infected wound on the Rt Hip.

The initial admission skin assessment showed the patient's skin was intact, good skin Turgor, no evidence of skin breakdown; "right hip Wound Type: right tibia fracture" (tibia is the bone found next to the fibula on the medial side of the leg, closer to the centre-line, between the knee and the ankle), with sterile dressing in place. The Braden Scale Assessment for predicting risk for pressure ulcer development revealed the patient was at risk for developing pressure ulcers (Braden Score 6 -18 = at risk) and the Nutrition Screen identified the patient to be at Moderate Risk.

There is documentation by the RNs in the medical record which shows that this patient developed hospital acquired pressure ulcers as follows:

1) 01 May 2014 - " boggy tissue on left heel.."
2) 05 May 2014 - Pressure Ulcer (PU) Location: Right heel, Stage I.
3) 18 May 2014 - Pressure Ulcer Location: Coccyx/Sacrum, Stage II.
4) 04 June 2014 - Pressure Ulcer Location: Lt. Lower Buttock, Stage II.
5) 12 June 2014 - Pressure Ulcer Location: Lt. Hip, Stage II.

The document however, does not show that interventions in the care plan were consistently provided and that the staff complied with the protocol for treatment of patients at risk for pressure ulcer and for those with skin breakdown. This is evidenced by the following:

1) The patient's care plan developed by the RNs, required turn and position q2hours (q.2.h. - every two hours), but this intervention was not consistently documented in the medical record. There was no documentation on April 3, 4, 5, 6, 23, 28 and 29th that the patient was turned and positioned q2 hours and with heels elevated off bed surface. These precautions are stated the facility's protocol for at risk patients. In addition, these intervention strategies for pressure relief were not consistently documented in the nurses' notes after the patient developed pressure ulcers.

This finding was reviewed with the head nurse at interview on 7/1/14 at approximately 11:30 AM. The head nurse acknowledged that the facility does not have a written turning schedule, but turning and positioning is documented in the nurses' notes.

2) Documentation in the medical record does not support that interventions were provided as per the facility's protocol:

(a) The provider was not notified and an occurrence form was not completed, both which are required by protocol when a pressure ulcer is first identified. This was confirmed at interview with the Director of Nursing PI on 7/2/14 at 10:00 AM.

(b) The pressure ulcer was not assessed every Wednesday (to determine stage, size, depth) and documented in the nursing progress notes. This required documentation was noted only on May 7, May 21 and June 26, 2014 when the pressure ulcer size/measurements were documented.

(c) The pressure ulcers to the Coccyx/Sacrum, Lt. Buttock and Rt Heel were assessed to be Necrotic beginning on June 30, 2014 and a referral was not made to the physician for assessment and evaluation of the need for surgical consult and/or debridement as specified in the protocol.

3) There is inconsistent documentation of all pressure ulcers; specifically, Pressure Ulcer (1) and Pressure Ulcer (5), and interventions and response to treatment was not documented for these pressure ulcers.

4) The pressure ulcer treatment provided was only documented on May 21, June 6, 10, 11, 18, 26 and July 1, 2014 and there was no documentation in the medical record of the frequency of the dressing change/treatments. The documentation throughout the medical record stated, "Dressing to pressure ulcer is dry and intact."

5) There is no documentation that the RN referred this patient to the Wound Specialist RN for an evaluation of her pressure ulcers. A Nursing Note for Pressure Dressing Change was documented by the Wound Specialist RN only on June 26, 2014.

At interview on July 2, 2014 at 10:30am, the Wound Specialist RN stated there is no policy for making referrals to the wound specialist. Referrals are made by the RNs when they do not agree with the staging of the wound or by the physician. Referrals are made through emails or phone calls, or may be also be obtained from daily rounds throughout the facility and from the facility's pressure ulcer list when the development/presence of pressure ulcer is put in the standard note for nursing PI. These pressure ulcers are investigated "depending on the stage or if the RN of MD calls."

The wound specialist stated that this patient was seen, but she did not document it in the medical record and she has no documentation to validate when this patient was assessed.

The facility also does not have a protocol with a formulary for pressure ulcer treatment. This was acknowledged at interviews with the Wound Specialist and with Nursing Director, PI.

6) The interventions provided did not appropriately address the patient's nutritional risk factors as evidenced by:

(a) The dietitian did not provide a timely initial assessment and did not provide timely reassessments when the patient was determined a high nutrition risk.

(b) The patient's low albumin (blood protein) level was not addressed and interventions were not provided in a timely manner. The patient's decreasing albumin level was documented on May 3, 14 and 17, 2014, and interventions were not addressed at that time.

(c) The dietitian did not address patient's tolerance of oral supplement and food preferences. There is documentation by the RNs throughout the medical record that "patient general eats only about ½ of food offered or receives less than optimum amount of liquid diet" and intervention was not implemented until June 15, 2014.

(d) Fluids and hydration was not addressed related to episodes of vomiting and skin breakdown.

(e) There is no documented nutrition protocol/interventions for pressure ulcers.

(f) There is no evidence that the dietitian discussed the patient's diet with the physician to determine the patient's protein intake and nutrition interventions for the low hematocrit (the volume percentage of red blood cells in blood) and albumin.

This patient acquired pressure ulcers approximately 27 days after admission to the facility and subsequently developed four (4) pressure ulcers; three (3) of which have deteriorated and are now unstageable.