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Based on staff interviews, facility document review, and patient record review, the facility failed to have an effective governing body to ensure that the facility provided Nursing Services to ensure patient safety; and ensure accountibility of the Medical
Staff in assessing the need for wound care. For these reasons, the Condition of Governing Body was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:

Referance A0338: Based on medical record review and medical staff interview the facility failed for 1 of 10 patients, (Patient #1), to ensure the accountability of the medical staff to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot


Refference A0385: Based on interview and record review the facility failed for 1 of 10 patients, (Patient #1), to ensure nursing supervision to prevent pressure sores and to develop and implement a care to prevent the the development of pressure sores.

Based on medical record review and medical staff interview the facility failed for 1 of 10 patients, (Patient #1), to ensure the accountability of the medical staff to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot

Findings:

Reference A0247: Based on medical record review and medical staff interview the medical staff failed for 1 of 10 patients, (Patient #1), to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot. The CAM boot remained on the patient for 8 days before the skin beneath the CAM boot was evaluated by a physician.

Based on medical record review and medical staff interview the medical staff failed for 1 of 10 patients, (Patient #1), to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot. The CAM boot remained on the patient for 8 days before the skin beneath the CAM boot was evaluated by a physician.

Findings:

Review of the medical record for patient #1 revealed an office visit History and Physical written on 11/05/2013 by Dr. #1 an orthopedic surgeon. The History and Physical was written as part of an outpatient surgical work up for patient #1. Review of the History and Physical revealed that the patient was to have surgery to repair a closed bimalleolar left ankle fracture suffered following a fall at home. Review of the physical examination of the ankle revealed " Inspection: fracture blisters, blood, and swelling. " Under Plan: " R/B discussed will proceed with OTIF, discussed compliance, elevation and possible loss of limb " .

Review of the medical record for patient #1 revealed an Emergency Room Provider Report dated 11/07/2013 " Pt was scheduled for a left ankle ORIF with Dr. #1 this morning and pt. had elevated BP at the outpatient surgical center this morning prior to her scheduled surgery. Pt was given 1 L NS, 10 mg Hydralazine, 10 mg Metoprolol and 1 mg Dilaudid with no improvement in her BP. Pt. arrived via EMS on stretcher, BP 222/86. Pt denies chest pain, dyspnea, weakness or stroke like S/S. Pt is verbal and states she lives alone, has no PCP, has no family here, pt ' s friend at bedside states they try to help as much as possible. Per Dr. #1 at bedside, pt. found on the floor in her own feces last week after a slip and fall and was Dx with an unstable ankle fracture. Dr. #1 has arranged for pt. to have ORIF at All Saints outpatient surgery center. Pt. states she takes no medications and has been taking Aleve for pain. Pt states she has history of HTN " years ago " ; 6 years ago she was able to stabilize her BP and tool herself of her BP medication. Pt ' s only C/O today is " a little pain to her ankle " . DNVI LLE. (Distal Neurovascular Intact " . Review of the Extremities Assessment section revealed " Stabilization boot in place to LLE, DNVI with no edema to the foot. " Review of the medical record did not reveal the ER physician or the ARNP ever removed the " boot " to evaluate the fracture blisters.

Review of the medical record for patient #1 revealed ER nursing notes/ED Final Patient Record revealed under Rapid Initial Assessment " Pt from Dr. #1 with c/o uncontrolled HTN was scheduled to have ankle fracture repaired this AM. " Additionally, under Objective Assessments the record revealed " Boot noted to LLE " . On page 2 of 7 under Physical Findings the Integumentary Assessment revealed WDP: Yes (WDP=within defined parameters) Review of page 6 of 7 under Assessment Parameters revealed the Integumentary assessment to be " Skin warm, dry and intact, No complaints of lesions, rash, wounds, bruises, petechial or abrasions " .

Review of the complete ER medical record failed to demonstrate that the boot was ever removed and the ankle/fracture blisters were assessed or that there were any treatment plans developed for the care of the fracture blisters. Review of the physician orders written in the ER revealed any orders related to the care and treatment of the fracture wounds.

Review of the ER medical records for patient #1 did not reveal that Dr. #1 provided any orders related to the utilization of the CAM Walker Boot or instructions on the care of the fracture blisters. The medical record did not reveal that any of the ER staff had contacted Dr. #1 for orders or instructions on the utilization of the CAM Walker Boot or instructions on the care of the fracture blisters.

Review of the History and Physical written on 11/07/2013 by Dr. #2 a Hospitalist and the attending physician for patient #1 revealed the following admission diagnosis Left ankle fracture, uncontrolled hypertension, UTI, Arthritis, Anemia. Possibly chronic no obvious blood loss, Possible acute renal failure with stage 3 and 4, and hyperglycemia. The treatments plan included Admit, IV fluids, IV antibiotics, Pain management, follow up with orthopedics for surgery, Hemoglobin A1c, Iv fluids and monitor kidney functions and EKG, normal sinus rhythm Patient is medically stable for surgical intervention with calculated moderate risk of perioperative morbidities, David tried to reach the family to get more information about the patient ' s home medications and medical issues, Ppi, and On Lovenox until surgery. Review of the Physical Exam revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the History and Physical did not reveal any reference to the two fracture blisters or any assessment of the conditions of the patient ' s skin under the boot.

Review of the Hospitalist progress note for 11/08/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the Assessment/Plan section revealed the following note " As per orthopedics they do not plan to do surgery for now, objective discharge and do that as outpatient. "

Review of the Hospitalist ' s progress note for 11/09/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: moves all, Normal capillary refill, normal range of motion, no edema, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot.

Review of the Hospitalist ' s progress note for 11/10/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: left empress left ankle dressing/, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot.

Review of the Hospitalist ' s Discharge Summary, (discharge was canceled), for 11/11/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: left hemiparesis left ankle dressing/, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot or provided any discharge instructions related to the care of the fractures blisters.

Review of the Hospitalist ' s progress notes for 11/12/212, 11/132013, and 11/14/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: left hemiparesis left ankle dressing, under Musculoskeletal: normal inspection, Lt leg with dressing 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot. Review of the Assessment/Plan section for 1112/213 revealed a note " Discussed case with Dr. #1 who is willing to do her surgery at the hospital but previously patient had elevated blood pressure and her blood pressures are still a bit to high will recheck labs and add Terazosin at hs ideally the plan would be to have surgery on Thursday the 14th. "

Review of the Physical exam section of the Hospitalist ' s progress note for 11/15/2013 revealed under Extremities: left hemiparesis left ankle dressing/, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5rt side ok and under Skin: dry, intact Review of the Assessment/Plan section revealed the following note dated 11/15/2013 " Patient status post open reduction internal fixation of left ankle and debridement of her fracture blisters after several days of good blood pressure control, patient had significant elevation of her medication prior to surgery, had a family conference with case management and the plan is to have the patient go home with family care and outside help as well, remove the Foley catheter and blood pressure monitoring, family understands the risk of aspiration, the patient has dysphasia, they will be trying to get her back to Canada. "

Review of the progress notes for 11/16/2013 and 11/17/2013 and the Discharge Summaries for 11/17/213 and 11/18/2013 did not reveal any references to the fracture blisters or the condition of the surrounding skin.

Review of the Orthopedic Consultation performed on 11/14/2013 by Dr. #1 revealed " On her examination, her CAM walker removed with the family present. She had fracture blisters initially. She has skin atrophic changes noted of the lower extremity. She has palpable dorsal pedis pulse. The Ulna boot that I have placed on the patient has since been removed. The swelling has decreased. There is diffuse ecchymosis throughout. I had a discussion with the son, the severity of this fracture, both the duration and the fact that she had fracture blisters and her hypertension, strict non-weight bearing will be necessary. "


Review of the nursing admission assessment for on 11/07/2013 at 1116 under the INTEGUMENTARY EVALUATION revealed the Skin Appearance: Appropriate for patient, Skin Temp: Warm, Skin Moisture: Dry, Skin Turgor: Good, Mucous Membrane: Dry. The assessment revealed Under WOUND/ULCER EVALUATION revealed Type #1 Blister Location: Lt Ankle x 2, Wound Evaluation: Non-open, Surrounding Tissue Evaluation: Normal, Wound Bed: Clear, Dressing: Ace Wrap with FZ Boot, Drainage Amount: None

Review of admission nursing note date 11/07/2013 at 1321 revealed " Received pt. Alert and Oriented times 3. No c/o pain or discomfort at present. IV patent infusing ABT at present. Left leg walking boot in place. Pt. vague with answering questions at present. Received pain med in ER. Friend with pt. Will observe. "

Review of a nursing note written 11/07/2013 at 1647 revealed " Spoke to Dr. #1. Dr. #1 stated that he was supposed to do surgery on pt ' s leg today, but he could not because he BP was elevated. Stated he will not see her at the hospital here but will on an outpatient basis when she is discharged. "

Based on interview and record review the facility failed for 1 of 10 patients, (Patient #1), to ensure nursing supervision to prevent pressure sores and to develop and implement a care to prevent the the development of pressure sores.

Findings:

Reference A0392: Based on record and staff interviews the facility failed for 1 of 10 patients( Patient #1) the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent the development of pressure sores on the left foot following a fracture.


Reference A0396: Based on staff interviews and record review the facility failed to for 1 of 10 patients, (patient #1), to develop, implement and revise an individualized Plan of Care with known fracture blisters beneath a CAM. walking boot.

Based on record and staff interviews the facility failed for 1 of 10 patients( Patient #1) the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent the development of pressure sores on the left foot following a fracture.

Findings:

Review of the medical record for patient #1 revealed an office visit History and Physical written on 11/05/2013 by Dr. #1 an orthopedic surgeon. The History and Physical was written as part of an outpatient surgical work up for patient #1. Review of the History and Physical revealed that the patient was to have surgery to repair a closed bimalleolar left ankle fracture suffered following a fall at home. Review of the physical examination of the ankle revealed " Inspection: fracture blisters, blood, and swelling. " Under Plan: " R/B discussed will proceed with OTIF, discussed compliance, elevation and possible loss of limb " .

Interview with Dr #1 on 1/2/14 revealed that he transferred the patient to the ER so that her blood pressure can be brought under control and then be discharged so the surgery could be done in the ASC.

Review of the medical record for patient #1 revealed an Emergency Room Provider Report dated 11/07/2013 " Pt was scheduled for a left ankle ORIF with Dr. #1 this morning and pt. had elevated BP at the outpatient surgical center this morning prior to her scheduled surgery. Pt was given 1 L NS, 10 mg Hydralazine, 10 mg Metoprolol and 1 mg Dilaudid with no improvement in her BP. Pt. arrived via EMS on stretcher, BP 222/86. Pt denies chest pain, dyspnea, weakness or stroke like S/S. Pt is verbal and states she lives alone, has no PCP, has no family here, pt. ' s friend at bedside states they try to help as much as possible. Per Dr. #1 at bedside, pt. found on the floor in her own feces last week after a slip and fall and was Dx with an unstable ankle fracture. Dr. #1 has arranged for pt. to have ORIF at All Saints outpatient surgery center. Pt. states she takes no medications and has been taking Aleve for pain. Pt states she has history of HTN " years ago " ; 6 years ago she was able to stabilize her BP and tool herself of her BP medication. Pt ' s only C/O today is " a little pain to her ankle " . DNVI LLE. (Distal Neurovascular Intact " . Review of the Extremities Assessment section revealed " Stabilization boot in place to LLE, DNVI with no edema to the foot. " Review of the medical record did not reveal the ER physician or the ARNP ever removed the " boot " to evaluate the fracture blisters.

Review of the medical record for patient #1 revealed ER nursing notes/ED Final Patient Record revealed under Rapid Initial Assessment " Pt from Dr. #1's with c/o uncontrolled HTN was scheduled to have ankle fracture repaired this AM. " Additionally, under Objective Assessments the record revealed " Boot noted to LLE " . On page 2 of 7 under Physical Findings the Integumentary Assessment revealed WDP: Yes (WDP=within defined parameters) Review of page 6 of 7 under Assessment Parameters revealed the Integumentary assessment to be " Skin warm, dry and intact, No complaints of lesions, rash, wounds, bruises, petechial or abrasions " .

Review of the complete ER medical record failed to demonstrate that the " boot was ever removed and the ankle/fracture blisters were assessed or that there were any treatment plans developed for the care of the fracture blisters. Review of the physician orders written in the ER revealed any orders related to the care and treatment of the fracture wounds.

Review of the ER medical records for patient #1 did not reveal that Dr. #1 provided any orders related to the utilization of the CAM Walker Boot or instructions on the care of the fracture blisters. The medical record did not reveal that any of the ER staff had contacted Dr. #1 for orders or instructions on the utilization of the CAM Walker Boot or instructions on the care of the fracture blisters.

Review of the History and Physical written on 11/07/2013 by Dr. #2, a Hospitalist, and the attending physician for patient #1 revealed the following admission diagnosis Left ankle fracture, uncontrolled hypertension, UTI, Arthritis, Anemia. Possibly chronic no obvious blood loss, Possible acute renal failure with stage 3 and 4, and hyperglycemia. The treatments plan included Admit, IV fluids, IV antibiotics, Pain management, follow up with orthopedics for surgery, Hemoglobin A1c, Iv fluids and monitor kidney functions and EKG, normal sinus rhythm Patient is medically stable for surgical intervention with calculated moderate risk of perioperative morbidities, David tried to reach the family to get more information about the patient ' s home medications and medical issues, Ppi, and On Lovenox until surgery. Review of the Physical Exam revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the History and Physical did not reveal any reference to the two fracture blisters or any assessment of the conditions of the patient ' s skin under the boot.


Review of Nursing Notes, (Clinical Documentation Record), dated 11/07/2013 at 1116 revealed a Nursing Admission Assessment for:
Integumentary WDP: N
INTEGUMENTARY EVALUATION:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Good
Mucous Membrane: Dry
WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Clear
Dressing: Ace Wrap with FX Boot
Drainage Amt: None

Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was clear but did not reveal if the dressing was removed, but did indicate that an ACE wrap was used with the CAM boot. The evaluation did not reveal if the wound bed was clear for both blisters or only one. The location on the left ankle of each blister was not documented.

Review of a nursing note written 11/07/2013 at 1647 revealed " Spoke to Dr.#1. Dr. #1 stated that he was supposed to do surgery on pt. ' s leg today, but he could not because he BP was elevated. Stated he will not see her at the hospital here but will on an outpatient basis when she is discharged. " Review of the medical record did not reveal that the nurse or a member of the nursing staff contacted the admitting physician to discuss the treatment of the wound or to obtain treatment orders for preventing a deterioration of the wounds.


Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/13 at 08:10 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Good
Mucous Membrane: Moist
Wound /Ulcer: Y
Incisions: N
New Onset of Skin Breakdown: N
Function of Bed/Mattress: Pressure Redistribution
WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal

Review of the Nursing Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record did not reveal if the wound beds were still clear or not reveal if the dressing was removed or changed or was not present. The location on the left ankle of each blister was not documented.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/2113 at 2000 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the wound, (Blisters) were evaluated at all during the shift.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/09/2013 at 09:39 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing: No Dressing
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple, Pink
Dressing: No Dressing

Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was Pink but did not reveal any information related to the dressing or if the CAM boot was on. The location on the left ankle of each blister was not documented. The development of the Ecchymosis skin located on the left knee was not evaluated as to cause or extent. There was not any documentation that the patient ' s physician was notified or treatment orders were obtained.

Review of the assessment on 11/09/2013 at 2146 was essentially the same as the one at 0939. The medical record did not reveal that the physician was not notified of the second wound are identified.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/10/2013 at 1004 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing: No Dressing
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple, Pink
Dressing: No Dressing

Review of the nursing documentation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound bed was Pink but did not reveal why dressing was removed or indicate if CAM boot was on. The location on the left ankle of each blister was not documented. The medical record did not reveal any physician orders for the treatment of the wounds or if the physician were ever notified. The assessment did not reveal if wound #2 had changed from the last assessment.


Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 2200 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Incisions: N
New Onset of Skin Breakdown: N
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing Mepilex
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple


Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound was dress with Mepilex but did not reveal that a physician was notified of the wound or that an order for using Mepilex for wound care was ordered. The record did not reveal if the CAM boot was on the patient. The location on the left ankle of each blister was not documented. The record did not reveal that the physician was notified of the wound on the knee or that any treatment orders were obtained by the nursing staff.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 0750 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 1900 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 0800 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 1641 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 0702 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 2032 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 0730 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.



Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 2015 revealed a Nursing Admission Assessment for:
Integumentary WDP: N
INTEGUMENTARY EVALUATION:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Good
Mucous Membrane: Dry
Wounds/Ulcer: Y
Incisions: N
New Onset Skin Breakdown: N
WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Unable to Assess
Comments Boot on LT Foot
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Left Knee
Surround Tissue Eva; Red
Type #3: Ecchymosis
Location: RT AC
Wound Eval: Non-Open
Surrounding Tissue Eval: Warm, Red, Swollen.

Review of the medical record revealed that the description of wound #3 was first described in this evaluation, contrary to stating No to New Onset of Skin Breakdown in the evaluation. The medical record revealed that surrounding tissue for wound #2 is now red.

Review of the Orthopedic Consultation performed on 11/14/2015 by Dr. #1 revealed " On her examination, her CAM walker removed with the family present. She had fracture blisters initially. She has skin atrophic changes noted of the lower extremity. She has palpable dorsal pedis pulse. The Ulna boot that I have placed on the patient has since been removed. The swelling has decreased. There is diffuse ecchymosis throughout. I had a discussion with the son, the severity of this fracture, both the duration and the fact that she had fracture blisters and her hypertension, strict non-weight bearing will be necessary. "

Review of photographs taken on 11/14/2014 in the presence of Dr. #1 revealed two fractures blister, one on the medial aspect of the ankle measuring 7 CM by 8 cm and one on the lateral side measuring 6 cm x 9 cm. The photographs revealed defuse ecchymosis from the lower top of her foot to mid-calf coming down of the back of leg to the top of her heel. Review of the medical record did not reveal any nursing assessment that described the conditions of the foot/ankle/leg or a plan of care to guide the treatment for the wounds.

Based on staff interviews and record review the facility failed to for 1 of 10 patients, (patient #1), to develop, implement and revise an individualized Plan of Care with known fracture blisters beneath a CAM. walking boot.

Findings

Review of the medical record for patient #1 revealed an office visit History and Physical written on 11/05/2013 by Dr. #1 an orthopedic surgeon. The History and Physical was written as part of an outpatient surgical work up for patient #1. Review of the History and Physical revealed that the patient was to have surgery to repair a closed bimalleolar left ankle fracture suffered following a fall at home. Review of the physical examination of the ankle revealed " Inspection: fracture blisters, blood, and swelling. " Under Plan: " R/B discussed will proceed with OTIF, discussed compliance, elevation and possible loss of limb " .

Interview with Dr #1 on 1/2/2013 at 11:00 AM revealed that he transferred the patient to the ER so that her blood pressure can be brought under controll and then be discharged so the surgery could be done in the ASC.

Review of the medical record for patient #1 revealed an Emergency Room Provider Report dated 11/07/2013 " Pt was scheduled for a left ankle ORIF with Dr. #1 this morning and pt. had elevated BP at the outpatient surgical center this morning prior to her scheduled surgery. Pt was given 1 L NS, 10 mg Hydralazine, 10 mg Metoprolol and 1 mg Dilaudid with no improvement in her BP. Pt. arrived via EMS on stretcher, BP 222/86. Pt denies chest pain, dyspnea, weakness or stroke like S/S. Pt is verbal and states she lives alone, has no PCP, has no family here, pt. ' s friend at bedside states they try to help as much as possible. Per Dr. #1 at bedside, pt. found on the floor in her own feces last week after a slip and fall and was Dx with an unstable ankle fracture. Dr. #1 has arranged for pt. to have ORIF at All Saints outpatient surgery center. Pt. states she takes no medications and has been taking Aleve for pain. Pt states she has history of HTN " years ago " ; 6 years ago she was able to stabilize her BP and tool herself of her BP medication. Pt ' s only C/O today is " a little pain to her ankle " . DNVI LLE. (Distal Neurovascular Intact " . Review of the Extremities Assessment section revealed " Stabilization boot in place to LLE, DNVI with no edema to the foot. " Review of the medical record did not reveal the ER physician or the ARNP ever removed the " boot " to evaluate the fracture blisters.

Review of the medical record for patient #1 revealed ER nursing notes/ED Final Patient Record revealed under Rapid Initial Assessment " Pt from Dr. #1's with c/o uncontrolled HTN was scheduled to have ankle fracture repaired this AM. " Additionally, under Objective Assessments the record revealed " Boot noted to LLE " . On page 2 of 7 under Physical Findings the Integumentary Assessment revealed WDP: Yes (WDP=within defined parameters) Review of page 6 of 7 under Assessment Parameters revealed the Integumentary assessment to be " Skin warm, dry and intact, No complaints of lesions, rash, wounds, bruises, petechial or abrasions " .

Review of the complete ER medical record failed to demonstrate that the " boot was ever removed and the ankle/fracture blisters were assessed or that there were any treatment plans developed for the care of the fracture blisters. Review of the physician orders written in the ER revealed any orders related to the care and treatment of the fracture wounds.

Review of the ER medical records for patient #1 did not reveal that Dr. #1 provided any orders related to the utilization of the CAM Walker Boot or instructions on the care of the fracture blisters. The medical record did not reveal that any of the ER staff had contacted Dr. #1 for orders or instructions on the utilization of the CAM Walker Boot or instructions on the care of the fracture blisters.

Review of the History and Physical written on 11/07/2013 by Dr. #2, a Hospitalist, and the attending physician for patient #1 revealed the following admission diagnosis Left ankle fracture, uncontrolled hypertension, UTI, Arthritis, Anemia. Possibly chronic no obvious blood loss, Possible acute renal failure with stage 3 and 4, and hyperglycemia. The treatments plan included Admit, IV fluids, IV antibiotics, Pain management, follow up with orthopedics for surgery, Hemoglobin A1c, Iv fluids and monitor kidney functions and EKG, normal sinus rhythm Patient is medically stable for surgical intervention with calculated moderate risk of perioperative morbidities, David tried to reach the family to get more information about the patient ' s home medications and medical issues, Ppi, and On Lovenox until surgery. Review of the Physical Exam revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the History and Physical did not reveal any reference to the two fracture blisters or any assessment of the conditions of the patient ' s skin under the boot.


Review of Nursing Notes, (Clinical Documentation Record), dated 11/07/2013 at 1116 revealed a Nursing Admission Assessment for:
Integumentary WDP: N
INTEGUMENTARY EVALUATION:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Good
Mucous Membrane: Dry
WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Clear
Dressing: Ace Wrap with FX Boot
Drainage Amt: None

Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was clear but did not reveal if the dressing was removed, but did indicate that an ACE wrap was used with the CAM boot. The evaluation did not reveal if the wound bed was clear for both blisters or only one. The location on the left ankle of each blister was not documented.

Review of a nursing note written 11/07/2013 at 1647 revealed " Spoke to Dr.#1. Dr. #1 stated that he was supposed to do surgery on pt. ' s leg today, but he could not because he BP was elevated. Stated he will not see her at the hospital here but will on an outpatient basis when she is discharged. " Review of the medical record did not reveal that the nurse or a member of the nursing staff contacted the admitting physician to discuss the treatment of the wound or to obtain treatment orders for preventing a deterioration of the wounds.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/13 at 08:10 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Good
Mucous Membrane: Moist
Wound /Ulcer: Y
Incisions: N
New Onset of Skin Breakdown: N
Function of Bed/Mattress: Pressure Redistribution
WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal

Review of the Nursing Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record did not reveal if the wound beds were still clear or not reveal if the dressing was removed or changed or was not present. The location on the left ankle of each blister was not documented.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/2113 at 2000 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the wound, (Blisters) were evaluated at all during the shift.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/09/2013 at 09:39 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing: No Dressing
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple, Pink
Dressing: No Dressing

Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was Pink but did not reveal any information related to the dressing or if the CAM boot was on. The location on the left ankle of each blister was not documented. The development of the Ecchymosis skin located on the left knee was not evaluated as to cause or extent. There was not any documentation that the patient ' s physician was notified or treatment orders were obtained.

Review of the assessment on 11/09/2013 at 2146 was essentially the same as the one at 0939. The medical record did not reveal that the physician was not notified of the second wound are identified.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/10/2013 at 1004 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing: No Dressing
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple, Pink
Dressing: No Dressing

Review of the nursing documentation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound bed was Pink but did not reveal why dressing was removed or indicate if CAM boot was on. The location on the left ankle of each blister was not documented. The medical record did not reveal any physician orders for the treatment of the wounds or if the physician were ever notified. The assessment did not reveal if wound #2 had changed from the last assessment.


Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 2200 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Incisions: N
New Onset of Skin Breakdown: N
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing Mepilex
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple


Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound was dress with Mepilex but did not reveal that a physician was notified of the wound or that an order for using Mepilex for wound care was ordered. The record did not reveal if the CAM boot was on the patient. The location on the left ankle of each blister was not documented. The record did not reveal that the physician was notified of the wound on the knee or that any treatment orders were obtained by the nursing staff.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 0750 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 1900 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 0800 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 1641 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 0702 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 2032 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 0730 revealed a Nursing Integumentary Evaluation that revealed:
Integumentary WDP: Y

Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above.

Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing.


Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 2015 revealed a Nursing Admission Assessment for:
Integumentary WDP: N
INTEGUMENTARY EVALUATION:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Good
Mucous Membrane: Dry
Wounds/Ulcer: Y
Incisions: N
New Onset Skin Breakdown: N
WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Unable to Assess
Comments Boot on LT Foot
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Left Knee
Surround Tissue Eva; Red
Type #3: Ecchymosis
Location: RT AC
Wound Eval: Non-Open
Surrounding Tissue Eval: Warm, Red, Swollen.

Review of the medical record revealed that the description of wound #3 was first described in this evaluation, contrary to stating No to New Onset of Skin Breakdown in the evaluation. The medical record revealed that surrounding tissue for wound #2 is now red.

Review of the Orthopedic Consultation performed on 11/14/2013 by Dr. #1 revealed " On her examination, her CAM walker removed with the family present. She had fracture blisters initially. She has skin atrophic changes noted of the lower extremity. She has palpable dorsal pedis pulse. The Ulna boot that I have placed on the patient has since been removed. The swelling has decreased. There is diffuse ecchymosis throughout. I had a discussion with the son, the severity of this fracture, both the duration and the fact that she had fracture blisters and her hypertension, strict non-weight bearing will be necessary. "


Review of the medical record for patient #1 revealed that on 11/07/2013 at 2100 that interventions, (Plan of Care) were developed to prevent the development of pressure sores. The patient was determined to be a low risk of developing pressure sores, (Braden Risk Scale of 16 or low). The interventions included:
Manage moisture. Avoid drying of the skin
Manage Nutrition. Maintain god hydration
Manage friction and shear
No massage of reddened bony prominence
Reposition Q2hrs and PRN
Offer toileting when turning.
Pericare PRN
Use moisture barrier: body wash and lotion routinely
Maximal remobilization-up in chair for meals when appropriate
Protect (offload) heels
Use turn sheet to reduce friction/shear
HOB <30 degrees unless medically contraindicated
Consider pressure relieving surface (if bed or chair bound)
Provide education on pressure ulcers to patient and family
Assess nutrition status. .Obtain nutrition consult PRN

Review of the medical record on 11/08/2013 at 0810 revealed the following was added to the skin care plan:
Use foam wedges for 30 degree lateral positioning
Consider trapeze if indicated
Monitor all body folds for moisture, yeast, rash, irritation.

Review of Nursing Notes, (Clinical Documentation Record), dated 11/09/2013 at 09:39 revealed a Nursing Integumentary Evaluation revealed the following:

Integumentary WDP: N
Integumentary Evaluation:
Skin Appearance: Appropriate for Patient
Skin Temp: Warm
Skin Moisture: Dry
Skin Turgor: Fair
Mucous Membrane: Moist
Wound /Ulcer: Y
Function of Bed/Mattress: Pressure Redistribution

WOUND/ULCER EVALUATION:
Type #1: Blister
Location:: Lt Ankle x 2
Wound Eval: Non-Open
Surround Tissue Eval: Normal
Wound Bed: Pink
Dressing: No Dressing
Type #2: Ecchymosis
Location: Left Knee
Wound Eval: Non-open
Surrounding Tissue Eval: Normal:
Wound Bed: Purple, Pink
Dressing: No Dressing

Review of the medical record did not reveal that the patient ' s care plan was updated to reflect the development of new area of Ecchymosis, (wound #2).

Review of the medical record revealed that the care plan remained essentially the same from the time first developed to the time of surgery. Review of the medical record did not reveal the fracture blisters or the areas, (Now two areas), of Ecchymosis, (areas wound #2 and Wound #3), were ever incorporated into the resident ' s care plan or that a treatment plan was ever developed to prevent skin breakdown.

Review of photographs taken on 11/14/2013 in the presence of Dr. #1 revealed two fractures blister, one on the medial aspect of the ankle measuring 7 CM by 8 cm and one on the lateral side measuring 6 cm x 9 cm. The photographs revealed defuse ecchymosis from the lower top of her foot to mid-calf coming down of the back of leg to the top of her heel. Review of the medical record did not reveal any nursing assessment that described the conditions of the foot/ankle/leg or a plan of care to guide the treatment for the wounds.



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