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A. Based on review of Hospital procedures, clinical record review (11 Pediatric Intensive Care patients), and staff interview, it was determined, that for 2 of 11 patients with nosocomial skin wounds, the Hospital failed to ensure skin wounds were measured in 1 of the 2 patients with nosocomial skin wounds (pt.#1) .

Findings include:

1. On 7/1/11 at 4:20 PM, the Wound/Burn Assessment and Dressing Change Procedures were reviewed. The Procedures required, "5. Measure wound area and depth using a disposable measuring device."

2. On 7/1/11 between 11:20 AM and 12:45 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 3-year-old female, admitted on 6/6/11 with diagnoses of Sub-glottic Stenosis, Premature Baby, Status Post VP Shunt, Feeding by Gastrostomy Tube, Chronic Lung Disease, and Tracheostomy Care. Pt. #1 ' s initial head to toe nursing assessment dated 6/6/11 at 3:00 PM included intact skin. Eleven days later, on 6/17/11 at 8:00 AM, the assessment included, " wound foot bilateral pressure sore bilateral heals ... clean dry red ... stage 1 ... dressing type - Duoderm to bilateral heels ... [and] wound head posterior pressure sore ... clean dry red, stage 1 ... dressing type - Mepelix ... " Measurement of heal wounds did not occur and measurement of the head wound was not completed until 6/29/11 at 7:19 PM, when the ulcer grew to Stage II, 2 cm length by 2 cm width, " Ulceration with pink and yellow center " .

3. These findings were confirmed the the Clinical Nurse Specialist Neonatal Intensive Care during interviews on 7/1/11 at approximately 1:15 PM and the Administrator of the Accreditation Readiness Department on 7/1/11 at 4:50 PM.

B. Based on review of Hospital protocol, clinical record review (11 Pediatric Intensive Care patients), and staff interview, it was determined, that for 1 of 11 patients (Pt. #1), the Hospital failed to ensure in patients at risk for skin breakdown were turned every 2 hours, if mobile, according to protocol.

Findings include:

1. On 7/1/11 at 11:20 AM, the "Skin Care (General) Management Protocol" was reviewed. The Protocol required, "Guidelines for use of the Modified Braden Q Skin Assessment Scale ... 3. If a patient has a score of less than 23, refer to the algorithm for interventions ... Skin Care Algorithm ... For the patient that can be turned: 1. Establish an aggressive turning schedule (q 2 hrs) ... "

2. On 7/1/11 between 11:20 AM and 12:45 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 3-year-old female, admitted on 6/6/11 with diagnoses of Sub-glottic Stenosis, Premature Baby, Status Post VP Shunt, Feeding by Gastrostomy Tube, Chronic Lung Disease, and Tracheostomy Care. Pt. #1 ' s Modified Braden Q Skin Scale assessments, completed between June 9 and June 18, included scores between 16 and 20, less than 23. Pt. #1 ' s nursing notes from admission to discharge, indicated that Pt. #1 could turn herself and did not include a physician's order that Pt. #1 could not be turned. There was no documentation that Pt. #1 had turned or had been turned every 2 hours.

3. On 6/17/11 at 8:00 AM, the assessment included, "wound foot bilateral pressure sore bilateral heals ... clean dry red ... stage 1 ... dressing type - duoderm to bilateral heels ... [and] wound head posterior pressure sore ... clean dry red, stage 1 ... dressing type - Mepelix ... " Subsequent documentation did not include turning every 2 hours. On 6/29/11 at 7:19 PM, the skin assessment included the head wound at Stage II, 2 cm length by 2 cm width, " Ulceration with pink and yellow center " .

4. These findings were confirmed the the Clinical Nurse Specialist Neonatal Intensive Care during interviews on 7/1/11 at approximately 1:15 PM and the Administrator of Accreditation Readiness Department on 7/1/11 at 4:50 PM.