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Based on record review, document review, policy review and staff interview it was determined the facility failed to identify, monitor, track and trend nursing compliance with wound care protocols as a high-volume or problem-prone area with significant impact on patient outcomes and quality of care.

Findings include:

A sample of 10 patient records included 6 patients (#1, #2, #3, #4, #8, #9) who were admitted with existing wounds. The 6 records of patients with existing wounds included 4 closed records (#1,
#2, #8, #9) and 2 open records (#3, #4).

The review of the 6 of 6 records of patients with wounds revealed no evidence of nursing assessment that included the measurement of the length, width and depth, the color, odor, drainage or stage of the wounds during the patients' hospitalizations. There was no evidence in 4 of the 4 closed records of nursing assessment of the status of the wounds, whether healed, improved, or worsened at the time of the patients' discharges. For 6 of the 6 sampled records there was no evidence of assessment by a member of the medical staff with regard to the measurement of the length, width and depth, the color, odor, drainage or stage of the wounds during the patients' hospitalizations. There was no assessment as to the status of the patients' wounds at the time of discharge for 4 of 4 closed records of patients with wounds.

A review of the Quality Assessment Performance Improvement (QAPI) indicators being tracked and trended for 2010, 2011, 2012, 2013 included an indicator for hospital acquired pressure ulcers. There were no other indicators with regard to skin or wound care.

Policy #PCM118, "Skin Care/Pressure Ulcer Care Protocol", last revised 11/2011 was reviewed on 7/24/13. Page 1., paragraph 2, Statement of Policy indicated the facility would conduct random monthly monitoring of the appropriate use, implementation and documentation of the initial and daily risk assessment tool and implementation of the appropriate nursing interventions with regard to skin care and prevention and treatment of pressure wounds.

A request to provide documentation of the monthly monitoring referred to in Policy #PCM118 revealed there was no documentation.

An interview was conducted with the Risk Manager on 7/24/13 at approximately 4:30 p.m. She confirmed the finding 6 of 6 sampled records of patients with wounds indicated the nursing staff was not assessing wounds the during the patients' hospitalizations and were not assessing the wounds at the time of discharge. She confirmed the finding the facility was not monitoring, tracking, trending, or analyzing data related to use of the assessment tool, implementation of appropriate nursing interventions, or patient outcomes with regard to wound care.

Based on record review, policy review, and staff interviews it was determined the registered nurse (RN):

Failed to appropriately assess and reassess 6 (#1, #2, #3, #4, #8, #9) of 6 patients of 10 sampled patients with wounds in compliance with facility policies. (Refer to A0395)

Failed to accurately and effectively implement the physician plan of care for 2 (#1, #4) of 6 patients of 10 sampled patients with wounds. (Refer to A0395)

Failed to ensure the nursing staff was in compliance with established policies for 3 (#1, #2, #9) of 6 patients of 10 sampled patients with wounds regarding skin care, prevention of pressure wounds, and nursing intervention in the care of patients with existing pressure wounds. (Refer to A0395)

Failed to develop and implement a nursing plan of care individualized to meet the needs of 3 (#1, #8, #9) of 6 patients of 10 sampled records with wounds. (Refer to A0396)


The cumulative effect of these systemic problems resulted in the facility not being in compliance with 42 CFR 418.23 Condition of Participation for Nursing Services.

Based on record review, policy review, and staff interviews it was determined the registered nurse failed to ensure patients were assessed and reassessed for 6 (#1, #2, #3, #4, #8, #9) of 6 patients of 10 sampled patients with wounds in compliance with facility policies. The registered nurse failed to accurately and effectively implemented the physician plan of care for 2 (#1, #4) of 6 patients of 10 sampled patients with wounds. The registered nurse failed to ensure compliance with policies regarding skin care, prevention of pressure wounds, and nursing intervention in the care of patients with existing pressure wounds for 3 (#1, #2, #9) of 6 patients of 10 sampled patients with wounds.

Findings include:

1. Patient #1 was admitted on 8/17/12 and discharged on 9/7/12. The consultation dated 8/17/13 and signed by the consulting physician included documentation the patient had a 0.9 centimeter (cm) x 0.5 cm Stage II decubitus ulcer on the coccyx at the time of admission. A review of all nursing documentation failed to reveal evidence the nursing staff measured the wound or determined the stage of the wound at any time during the patient's admission. There was no assessment of the status of the wound at the time the patient was discharged.

2. Patient #2 was admitted on 7/7/13 and discharged on 7/17/13. The History and Physical dated 7/8/13 noted the patient had an abrasion over the left knee, contusion abrasion of the stump of his left below-knee amputation, and an abrasion on the right leg. The Adult Admission History/Assessment (initial nursing assessment) dated 7/7/13 at 10:00 p.m. indicated a small skin tear above the left knee and a small skin abrasion below the left knee. There was no further description of the wounds. The shift assessment dated 7/8/13 at 7:30 a.m. indicated "wound" below the patient's left knee on the body diagram. The shift assessment dated 7/8/13 at 7:00 p.m. indicated the patient had a skin tear below his left knee on the body diagram. There were no further description of the wounds. The shift assessments dated 7/9/13 at 7:30 a.m. and 10:00 p.m. indicated the patient had no wounds and his skin was normal. The shift assessment dated 7/17/13 at 7:10 a.m. noted "some skin tears, buttocks red" with no further description of the abnormalities. There patient was discharged.

3. Patient #3 was admitted on 7/14/13 and was currently in the Intensive Care Unit (ICU). The History and Physical dated 7/15/13 revealed the examination of the patient's back and sacral area showed "2 or 3 wounds. There are ulcers which are stage II, stage III." The Nursing Wound Care form dated 7/23/13 at 10:00 p.m. indicated Site 1 was a deep stage II pressure ulcer on the patient's left heel; Site 2 was a stage II pressure wound on the patient's right lateral calf, and Site 3 was a stage III pressure ulcer on the patient's coccyx. Review of all of the nursing documentation failed to reveal the measurement of the length, width, or depth of the wounds at any time during the patient's hospitalization. With the exception of the assessment dated 7/23/13, there was no evidence of any assessment or reassessment of the stage, appearance, or size of the patient's wounds.

ICU RN #1 was interviewed on 7/24/13 at approximately 9:30 a.m. She confirmed she was the nurse assigned to Patient #3. In response to questions, she indicated she could not determine whether the patient's wounds had improved since he was admitted. She confirmed the finding that prior nursing assessments did not include the stage, appearance, or size of the patients wounds. She confirmed the finding as a result of the lack of assessment she was unable to determine if the current interventions were effective or not, or if a change in the plan of care was indicated.

4. Patient #4 was admitted on 7/10/13 and was currently in the Adult Care Unit (ACU). The review of the nursing documentation failed to reveal evidence of the assessment of the size, depth or appearance of the wound of the patient's left foot.

ACU RN #1 was interviewed on 7/24/13 at approximately 10:45 a.m. In response to questions, she indicated the nurses do not measure or stage wounds. She was unable to describe how she would determine if a wound was improving or worsening other than "by how it looks."

5. Patient #8 was admitted on 7/7/13 and discharged on 7/16/13. The Consultation dated 7/8/13 was signed by the wound care physician. The Physical Examination included documentation there was an open wound and bruises on the patient's lower extremities without surrounding erythema. The Adult Admission History/Assessment (initial nursing assessment) did not include documentation of any wounds or skin abnormalities. Review of all of the nursing documentation failed to reveal assessment or reassessment of the length, width, depth, appearance, drainage or odor associated with the wound. There was no evidence the status of the wound was assessed at the time of the patient's discharge on 7/16/13.

6. Patient #9 was admitted on 7/9/13 and discharged on 7/15/13. The History and Physical dated 7/9/13 was signed by the attending physician. The Physical Examination included documentation the patient had "1 or 2 decubitus on the back". The Adult Admission History/Assessment (initial nursing assessment) dated 7/9/13 at 7:00 p.m. was not signed. The skin assessment did not indicate the patient had any wounds. The shift assessment dated 7/10/13 at 8:00 a.m. indicated the patient had blanchable areas of redness on the hip and posterior knee. The shift assessment date 7/10/13 (no time indicated) indicated the patient had a reddened area on the coccyx. The shift assessment dated 7/11/13 at 8:00 a.m. indicated no wounds or skin abnormalities. The shift assessment dated 7/11/13 at 8:00 p.m. indicated the patient had a stage II pressure ulcer on the coccyx. Review of all the nursing documentation failed to reveal any evidence the nursing staff measured the length, width, depth, appearance, drainage, or odor of the patient wounds at any time during her hospitalization. There was no evidence the status of the patient's wound or that the wounds were assessed at the time of the patient's discharge on 7/15/13.

The facility policy "Skin Care/Pressure Ulcer Protocol", Policy #PCM118, last revised 11/2011, was reviewed on 7/24/13. Paragraph 3, section 4. indicated if a patient is admitted with a pressure ulcer, the nurse must document the stage, length, width, and depth in centimeters, location, drainage, tunneling, appearance and odor. Section 6. stated wound measurements will be done on admission, every 7 days, and on discharge.

An interview was conducted with the Risk Manager and the Interim Chief Nursing Officer (CNO) on 7/24/13 at approximately 11:30 a.m. They confirmed the finding of on-going non-compliance of the nursing staff with facility polices on assessment and reassessment of wounds.


7. Patient #1 was admitted on 8/17/12 and discharged on 9/7/12. Consultation dated 8/17/13 and signed by the consulting physician noted the patient had a 0.9 cm x 0.5 cm Stage II decubitus ulcer on the coccyx at the time of admission. The physician orders dated 8/17/12 at 11:45 a.m. and signed by the consulting surgeon included directions to place a specialty dressing to the patient's coccyx area. The physician orders dated 8/19/12 at 6:30 a.m. and signed by the consulting surgeon included an order to get the patient out of bed to a chair with assistance that afternoon. The physician orders dated 8/21/12 at 3:55 p.m. included an order to check the sacral decubitus every 72 hours and change the specialty dressing on the sacral decubitus every 72 hours. The physician orders dated 8/28/12 at 4:30 p.m. included an order to draw a Vancomycin Trough level (blood test) on 8/30/12 at 8:00 a.m. The physician orders dated 9/6/12 at 1:30 p.m. included an order requesting Physical Therapy to please assist the patient to a chair at least two times daily for one hour. A review of all nursing documentation failed to reveal any evidence the patient had a specialty dressing applied to the decubitus ulcer on the coccyx on 8/17/12 as ordered by the physician. There was no evidence the specialty dressing on the patient's decubitus was checked or changed every 72 hours as ordered by the physician on 8/21/12.

The Adult 24 Hour Nursing Flow Sheet dated 8/19/12 included a section labeled Activity/Exercise Patterns with a space to indicate the number of times the patient was up to a chair on each shift. The areas were blank for both shifts on 8/19/12. The Nursing Notes dated 8/19/12 contained no evidence the patient was assisted to a chair. The report of the results of the Vancomycin Trough level dated 8/30/12 indicated the blood specimen had been collected at 4:15 a.m., not 8:00 a.m. as ordered by the physician on 8/28/12. There was no evidence the patient was assisted to a chair at any time by either Physical Therapy or the nursing staff on 9/6/12 or 9/7/12 as ordered by the physician.

8. Patient #4 was admitted on 7/10/13 and was currently in the ACU. Physician Orders dated 7/10/13 and signed by the physician included an order for dressing changes to be performed twice daily. Review of the Nursing Notes revealed documentation the dressing was changed once on 7/10/13 on the day shift and once on 7/11/13 on the day shift. There was no evidence of any dressing changes on 7/13/13. There was no evidence a second dressing change was performed on the night shift on 7/14-7/21/13 and 7/23/13.

An interview was conducted with the Risk Manager on 7/25/13 at approximately 3:00 p.m. She confirmed the above findings.


9. Patient #1 was admitted on 8/17/12 and discharged on 9/7/12. The Consultation dated 8/17/13 and signed by the consulting physician noted the patient had a 0.9 cm x 0.5 cm Stage II decubitus ulcer on the coccyx at the time of admission. The Adult Admission History/Assessment (initial nursing assessment) dated 8/17/12 indicated the patient had a Skin Integrity Profile score of 8, indicating the nurse was to notify Wound Care. A review of the entire medical record failed to reveal evidence of nursing notifying Wound Care or implementing the Skin Care Protocol.

10. Patient #2 was admitted on 7/7/13 and discharged on 7/17/13. The History and Physical dated 7/8/13 indicated the patient had an abrasion over the left knee, contusion abrasion of the stump of his left below-knee amputation, and an abrasion on the right leg. The Adult Admission History/Assessment (initial nursing assessment) dated 7/7/13 at 10:00 p.m. indicated a small skin tear above the left knee and a small skin abrasion below the left knee. The Skin Integrity Profile indicated the patient had a score of 11, indicating the nurse was to notify Wound Care. A review of the entire medical record failed to reveal evidence of nursing notifying Wound Care or implementing the Skin Care Protocol.

11. Patient #9 was admitted on 7/9/13 and discharged on 7/15/13. The History and Physical dated 7/9/13 was signed by the attending physician. The Physical Examination included documentation the patient had "1 or 2 decubitus on the back". The Adult Admission History/Assessment (initial nursing assessment) dated 7/9/13 at 7:00 p.m. indicated the patient had a Skin Integrity Profile score of 11, indicating the nurse was to notify Wound Care. A review of the entire medical record failed to reveal evidence of nursing notifying Wound Care or implementing the Skin Care Protocol.

The facility policy "Skin Care/Pressure Ulcer Protocol", Policy #PCM118, last revised 11/2011, was reviewed on 7/24/13. Page 1, Paragraph 3, section 2. indicated the if the Skin Integrity Profile score is 8 or more, initiate the skin care protocol. Page 2, Skin Care Protocol included 4. provide air cushion for patients of limited movement or who had recent prolonged periods of immobility; specialty beds or mattresses are to be used according to a needs assessment and require a physician's order; 5. for any identified pressure area initiate physician standing orders; 7. apply oils, moisturizer, creams, immediately after bathing; 9. cleanse skin tears, pat dry, protect surrounding skin with barrier wipe.

An interview was conducted with the Risk Manager on 7/25/13 at approximately 3:00 p.m. She confirmed the above findings.

Based on record review, policy review, and staff interview it was determined the facility failed to ensure the nursing staff developed and implemented an individualized plan of nursing care to meet the needs of 3 (#1, #8, #9) of 6 patients of 10 sampled patients with wounds.

Findings include:

1. Patient #1 was admitted on 8/17/12 and discharged on 9/7/12. The Consultation dated 8/17/13 and signed by the consulting physician noted the patient had a 0.9 cm x 0.5 cm Stage II decubitus ulcer on the coccyx at the time of admission. Additional documentation included the patient was an paraplegic. s.

Physician Orders dated 8/17/12 at 11:45 a.m. and signed by the consulting surgeon included directions to place a specialty dressing to the patient's coccyx area. The Physician Orders dated 8/21/12 at 3:55 p.m. included an order to check the sacral decubitus every 72 hours and change the specialty dressing on the sacral decubitus every 72 hours.

A review of the Interdisciplinary Plan of Care for Patient #1 revealed section 12. Skin Integrity (15 or less) At Risk for Skin Impairment. This section of the care plan was blank. Section 13. Skin Integrity Skin Impairment included a goal of wound improvement and interventions including skin/wound care protocol, specialty mattress, photo of wound, turn patient, trigger nutritional services, and wound care flow sheet. This section was signed by an RN and dated 8/21/12 indicating the goal of wound improvement and the interventions of specialty mattress and trigger nutritional services were initiated 4 days following the admission of a paraplegic patient with an existing Stage II decubitus ulcer. Section 14. Immobility was blank. The document was dated and signed as having been reviewed by an RN each day of the patient's hospitalization. There was no evidence the plan of care had been individualized to include the wound care directed by the physician. The record contained no reassessment of the stage of the patient's decubitus ulcer over the course of the 21 day hospitalization. The care plan did not include documentation of any plan of care related to a specific wound stage.

2. Patient #8 was admitted on 7/7/13 and discharged on 7/16/13. The Consultation dated 7/8/13 was signed by the wound care physician. The Physical Examination included an open wound and bruises on the patient's lower extremities without surrounding erythema. Review of all of the nursing documentation failed to reveal evidence of the implementation of the Skin Care Protocol.

3. Patient #9 was admitted on 7/9/13 and discharged on 7/15/13. The History and Physical dated 7/9/13 was signed by the attending physician. The Physical Examination noted the patient had "1 or 2 decubitus on the back". The shift assessment dated 7/11/13 at 8:00 a.m. indicated no wounds or skin abnormalities. The shift assessment dated 7/11/13 at 8:00 p.m. indicated the patient had a stage II pressure ulcer on the coccyx. Review of all the nursing documentation failed to reveal any evidence the nursing staff implemented the Skin Care Protocol

The facility policy "Skin Care/Pressure Ulcer Protocol", Policy #PCM118, last revised 11/2011, was reviewed on 7/24/13. Page 4, paragraph 2, Procedure, 2. indicated the nurse will individualize the plan for the care and management of the specifically identified stage. Page 1, Paragraph 3, section 2. indicated the if the Skin Integrity Profile score is 8 or more, initiate the skin care protocol. Page 2, Skin Care Protocol included 4. provide air cushion for patients of limited movement or who had recent prolonged periods of immobility; specialty beds or mattresses are to be used according to a needs assessment and require a physician's order; 5. for any identified pressure area initiate physician standing orders; 7. apply oils, moisturizer, creams, immediately after bathing; 9. cleanse skin tears, pat dry, protect surrounding skin with barrier wipe.

An interview was conducted with the Risk Manager on 7/25/13 at approximately 3:00 p.m. She confirmed the above findings.