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Based on record review and staff interview the facility failed to ensure a Registered Nurse supervised and ensured provision of care for 3 of 3 patients reviewed for pressure ulcers (Patients# 1, 2, and 6) for accurate weekly wound assessments with measurements and to ensure 2 of 3 patients reviewed for pressure ulcers (Patients# 1 and 2) received the assistance they needed for turning and repositioning to prevent development or worsening of pressure ulcers.

The findings included:

1) Review of the record revealed Patient #1 was admitted to the facility on 05/16/18. Patient #1's physician's "Progress Note" dated 05/18/18 at 9:12 AM documented Patient #1's diagnoses included a sacral pressure ulcer and paraplegia secondary to a spinal abscess, that Patient #1 was incontinent of bowel and bladder and required moderate assistance of 1 person to turn from side to side in bed, and that the plan included to monitor for incontinence and turn Patient #1 every 2 hours and as needed. Patient #1's "Physician Orders" dated 05/17/18 included to do a Skin/Wound Assessment on admission, turn Patient #1 every 2 hours (when in bed), reposition every 30 minutes when in a chair, assist and encourage to turn and reposition frequently when in bed. Patient #1's "Interdisciplinary Plan of Care" with a service date/time of 05/16/18 at 10:58 PM documented in Integumentary (skin) interventions, last update 05/17/18 at 2:38 AM, to monitor for incontinence every 2 hours and as needed and initiate a toileting schedule/change incontinence pad as needed.

Review of the record revealed no measurements of Patient #1's sacral wound upon admission although a photo was taken of the wound. The photo was blurred and showed an irregular round open wound with the patient's identification label on an area of skin closest to the camera. The size of the wound could not readily be determined so as to evaluate for wound healing or deterioration with treatment. Review of Patient #1's "Wound View Flow Sheet" reveals no documentation of the stage or size of Patient #1's sacral wound until 5 days after admission, on 05/21/18, at which time it was documented as a Stage "3," and no wound measurements until 6 days after admission, on 05/22/18, at which time the wound was documented 6 cm (centimeters) long by 5 cm wide by 0.2 cm deep. Photographs of the wound with a ruler labeled 05/22/18 at 8:21 AM and 05/24/18 at 8:25 AM showed the open wound had changed shape and appeared to have 2 new areas of expansion exposing red tissue. Without the benefit of a quantitative admission wound assessment, the progress of wound treatment since admission could not be determined. Patient #1 left the facility on 05/26/18 without further evidence of wound measurements.

Review of the record also revealed no evidence of documentation that Patient #1 had been checked for incontinence and offered assistance to turn every 2 hours as ordered. Keeping the wound area clean and relieving pressure points are important to wound healing and preventing further skin breakdown.

During an interview on 08/27/18 at 2:51 PM, the Chief Nursing Officer reported the Wound Care Nurse does wound measurements and takes pictures of wounds within 3 days of admission, upon identification of new wounds, and weekly on Wednesdays, but admitted she could find no evidence of wound measurements on admission for Patient #1.

During an interview on 08/27/18 at 12:26 PM, Charge Nurse "A" reported nurses and techs turn patients if needed, that the nurses do patient rounds on even hours, and techs on odd hours. Upon inquiry regarding the routine for turning patients, Charge Nurse "A" explained patients have to be able to do 3 hours of therapy a day in order to be in the facility, so they should not be totally bedbound.

2) Review of the record revealed Patient #2 was admitted to the facility on 06/14/18 with diagnoses that included hip and pelvic fractures and end stage renal disease. Patient #2's Admission History and Physical documented Patient #2 was incontinent of bowel, required total assist with mobility and activities of daily living, and that her therapy goals included to be able to roll side to side in bed without help. Patient #2's admission skin assessment documented bruising (location unknown) but no evidence of documentation of pressure ulcers or other wounds. A photograph of Patient #2's buttocks dated 06/15/18 at 4:23 AM shows redness to the lower back and right buttock and a darkened area over the right ischium, which should indicates Patient #2's increased risk for developing a pressure ulcer and the presence of a possible deep tissue injury. However, there was no evidence of interventions added to the care plan to address Patient #2's increased risk of skin breakdown, of teaching to the patient/family, or of further assessment such as to determine whether the reddened areas were blanchable and of Patient #2's ability and willingness to turn themselves, or physician notification of the redness and darkened area over a bony prominence.

"Integumentary" notes dated 06/21/18 documented a left heel pressure ulcer and a gluteus (buttock) wound measuring 4 cm by 5 cm. A photograph dated 06/21/18 shows an open area to the left buttock as well as redness and smaller darkened areas to the sacrum and left buttock. Patient #2's Physician orders dated 06/21/18 included a wound team consult for gluteal and heel wounds, daily wound care instructions, to offload Patient #2's heels from the bed with a pillow, and to turn and reposition Patient #2 frequently when in bed. Occupational Therapy notes dated 06/18/18 documented Patient #2 required minimal to moderate assistance to roll in bed. Physical Therapy notes on 06/22/18 documented Patient #2 required maximum assistance for bed mobility.

Patient #2's "Activity Tracking" revealed the first documentation of a turn since admission on 06/19/18 at 6:27 AM. The next documentation of a turn, "max assist to roll," was an entry on 06/24/18 at 9 PM. Patient #2's "Activity Tracking" entry on 06/25/18 documented a weight shift at 9:09 PM and that Patient #2 required 2 helpers and maximum assistance to roll left and right. Patient #2's "Activity Tracking" entries on 06/26/18 documented a weight shift at 2:11 AM and maximum assist to roll at 9:38 PM. There was no evidence of documentation that Patient #2 was offered and provided the necessary assistance to turn every 2 hours or that Patient #2's heels were offloaded to prevent further breakdown.

There was no evidence of wound reassessment before Patient #2 left the facility 8 days later for a higher level of care on 06/29/18.

During an interview on 08/27/18 at 2:51 PM, the Chief Nursing Officer stated measurements of the wounds should have been completed on 06/27/18 during weekly wound assessments.

During an interview on 08/27/18 at 3:06 PM, the Wound Care Nurse reported all pressure ulcers including Stage 1 (persistent redness) and suspected deep tissue injuries are referred to herself and that she updates wound assessments weekly, on Wednesdays, but was not in the facility on 06/27/18. The Wound Care Nurse reviewed the photograph of Patient #2's buttocks from 06/15/18 with the darkened area over the ischium (seat bone) but stated that it was not a pressure ulcer because she said it wasn't over a bony prominence and she wouldn't expect the staff nurse to refer it to her unless the patient was complaining of pain.

3) Review of the record revealed Patient #6 was admitted to the facility on 08/03/18 with diagnoses that included stroke and diabetes. Patient #6's skin assessment documented presence of a sacrum pressure ulcer that was cleansed but no measurements of the wound. A photograph provided by the facility with a handwritten date of 8/3/18 and no ruler or indicator of scale shows an open area to the right buttock and 2 dark purple areas to the left buttock with surrounding skin pink to light pink.

Review of Wound View flowsheet reveals the first measurement of Patient #6's wound on 08/06/18, Patient #6's 4th day in the facility, at 10 cm by 6 cm with minimal exudate (drainage). A photograph dated 8/13/18 shows new open areas to the left buttock with yellow slough and central eschar (dark dead tissue) to the lower left wound with dark pink areas between and immediately surrounding the wounds. A photograph dated 08/27/18 shows yellowish green exudate to all 3 open areas (one on the right buttock and 2 on the left buttock) and a large area of deep red skin to most of the visible buttocks area that extends to the inner thighs.

Review of the Wound View flowsheet reveals that the wound was documented as having scant to no drainage/exudate with assessments from 08/03/18 to 08/17/18. (Although there are 3 distinct open areas in the pictures beginning with 08/13/18, the facility's documentation and measurements are of one large wound.) Further review of the Wound View flowsheet reveals documentation that the wound had moderate drainage on 08/20/18, 08/21/18, 08/24/18, 08/26/18, 08/27/18, that the surrounding area had changed from light red/pink to "bright red" on 08/27/18.

Despite the change from 1 open area and a suspected deep tissue injury to 3 open areas with full thickness loss of skin and slough during Patient #6's stay, the increase in exudate from "none" to "moderate" and enlarging surrounding area of deepening redness around the wounds, pressure ulcer assessments on the Wound View flowsheet continued to document signs of infection as "none" and the pressure ulcer status as "unchanged," except for one entry of "improving" on 08/10/18.

During interview with the Wound Care Nurse on 08/27/18 at 3:57 PM, she explained from admission until 08/15/18 she only used barrier cream on the wound because Patient #6 was incontinent of stool several times a day and she did not want stool to get in a dressing and on the wound. Upon further inquiry, she could not explain how having an open wound on the buttocks uncovered could protect it from fecal contamination. The Wound Care Nurse admitted she did not consult a Wound Care physician because she would only do so for the purpose of debridement and, since Patient #6 had diarrhea, she wouldn't advise debridement of the wounds. The Wound Care Nurse reported the physician ordered wound care with "Therahoney," gauze and Optifoam dressing on 08/15/18 and changed it to "Santyl," gauze and Optifoam dressing on 08/23/18.

During interview with a physician who attended Patient #6, Physician "B" on 08/27/18 at 4:30 PM, he reported when Patient #6's wound "opened" he changed the order to Therahoney (order date 08/15/18 as noted), and later to Santyl. Upon viewing the photograph with bilateral open areas dated 08/13/18, Patient #6's physician said he did not see it that day but a few days later.

Based on record review and staff interview the facility failed to ensure the nursing care plan was updated to reflect the care needs for 1 of 3 patients reviewed for pressure ulcers (Patient #2).

The findings included:

Review of the record revealed Patient #2 was admitted to the facility on 06/14/18 with diagnoses that included hip and pelvic fractures and end stage renal disease. Patient #2's Admission History and Physical documented Patient #2 was incontinent of bowel, required total assist with mobility and activities of daily living, and that her therapy goals included to be able to roll side to side in bed without help. Patient #2's admission skin assessment documented bruising (location unknown) but no evidence of documentation of pressure ulcers or other wounds. A photograph of Patient #2's buttocks dated 06/15/18 at 4:23 AM shows redness to the lower back and right buttock and a darkened area over the right ischium, which should have alerted staff to Patient #2's increased risk for developing a pressure ulcer and the presence of a possible deep tissue injury. However, there was no evidence of interventions added to the care plan to address Patient #2's increased risk of skin breakdown, of teaching to the patient/family, or of further assessment such as to determine whether the reddened areas were blanchable and of Patient #2's ability and willingness to turn themselves, or physician notification of the redness and darkened area over a bony prominence.

"Integumentary" notes dated 06/21/18 documented a left heel pressure ulcer and a gluteus (buttock) wound measuring 4 cm by 5 cm. A photograph dated 06/21/18 shows an open area to the left buttock as well as redness and smaller darkened areas to the sacrum and left buttock. Patient #2's Physician orders dated 06/21/18 included a wound team consult for gluteal and heel wounds, daily wound care instructions, to offload Patient #2's heels from the bed with a pillow, and to turn and reposition Patient #2 frequently when in bed. Occupational Therapy notes dated 06/18/18 documented Patient #2 required minimal to moderate assistance to roll in bed. Physical Therapy notes on 06/22/18 documented Patient #2 required maximum assistance for bed mobility.

Patient #2's "Activity Tracking" revealed the first documentation of a turn since admission on 06/19/18 at 6:27 AM. The next documentation of a turn, "max assist to roll," was an entry on 06/24/18 at 9 PM. Patient #2's "Activity Tracking" entry on 06/25/18 documented a weight shift at 9:09 PM and that Patient #2 required 2 "helpers" and maximum assistance to roll left and right. Patient #2's "Activity Tracking" entries on 06/26/18 documented a weight shift at 2:11 AM and maximum assist to roll at 9:38 PM. There was no evidence of documentation that Patient #2 was offered and provided the necessary assistance to turn every 2 hours or that Patient #2's heels were offloaded to prevent further breakdown.

During an interview on 08/27/18 at 3:06 PM, the Wound Care Nurse reported all pressure ulcers including Stage 1 (persistent redness) and suspected deep tissue injuries are referred to herself and that she updates wound assessments weekly, on Wednesdays, but was not in the facility on 06/27/18. The Wound Care Nurse reviewed the photograph of Patient #2's buttocks from 06/15/18 with the darkened area over the ischium (seat bone) but stated that it was not a pressure ulcer because she said it wasn't over a bony prominence and she wouldn't expect the staff nurse to refer it to her unless the patient was complaining of pain.

During an interview on 08/27/18 at 12:26 PM, upon inquiry regarding the routine for turning patients, Charge Nurse "A" explained patients have to be able to do 3 hours of therapy a day in order to be in the facility, so they should not be totally bedbound.