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Based on review of medical records, staff interviews and observations, the facility failed to ensure that care for each patient was appropriate in accordance with acceptable standards of practice. Specifically, the facility failed to ensure nurses documented patient care, including repositioning and turns, in a consistent and trackable manner, particularly in two of twenty (#13, #20) sample medical records wherein the patient's skin was at high risk for breakdown/wounds.

This failure has the potential for negative patient outcome.

Findings:

1. The facility failed to ensure that nursing staff documented each time a patient was turned or repositioned.

a) Sample Patient #13 was an adult with a history of hypertension and obesity. S/he presented to the Emergency Department on 01/10/12 with a complaint of chest pain and shortness of breath. S/he was diagnosed with a pulmonary embolism and deep vein thrombosis. The patient then developed hypoxic respiratory failure, was intubated and admitted to the Intensive Care Unit (ICU), where s/he remained intubated with moderate sedation for 10 days. Nursing documentation on 01/11/12 noted that the Patient's skin was intact. On 01/16/12 documentation noted that the patient had an unstageable decubitus ulcer.

b) On 12/19/12 a review of the medical record for Sample Patient #13 revealed the following documentation every 12 hours: "Activities of Daily Living, Patient Position; Right Side, Left Side, Supine, Patient Activity; Bedrest, Turn every 2 hours." Nursing documentation noted that the patient was a high risk for skin break down and one of the interventions was to turn the patient every one hour and as needed. There was no additional documentation by nursing staff as to when the turns were being performed.

c) On 12/19/12 at 1:55 p.m. an interview with the facility's Quality Assurance Director was conducted. S/he stated that the above documentation is stating that the patient was turned every two hours during the 12 hour shift in that particular order. S/he also stated that the nursing staff charts only by exception.

d) Sample Patient #20 was an adult who lived in a skilled nursing facility with a history of hypertension, diabetes, atrial fibrillation, bipolar disorder, reactive airway disease, congestive heart failure, depression, schizophrenia and is wheelchair bound. S/he presented to the facility's Emergency Department on 12/16/12 with a complaint of fever, shortness of breath and rash. A physical exam of the patient was performed by the physician and the following was noted: "patient with a large area of purple/red discoloration to left proximal thigh. Distal to this there is an area of light pink discoloration with warmth most consistent with cellulitis of the left medial thigh right lower extremity lateral lower leg with redness and warmth. Buttocks with multiple decubitus ulcers and the appearance of sinus tracts. All these areas without crepitus." The patient was diagnosed with sepsis, cellulitis, atrial fibrillation with rapid ventricular response, renal insufficiency and an elevated troponin. On 12/17/12 at 2:00 a.m. the patient was admitted to the ICU in critical condition.

e) On 12/20/12 the medical record for Sample Patient #20 was reviewed. The admitting nurses skin assessment stated that the patient was a moderate risk and one of the interventions was to turn the patient every two hours and as needed. Medical record review also revealed multiple places to document a patients position.

One place the patient's position could be documented was in the "ICU Monitor Vital Signs: Patient Position During Blood Pressure" section of the electronic record. A review of these documents revealed the following: Position documented as "Supine" from 12/17/12, 7:00 a.m. - 1:00 p.m. (6 hours). Position documented as "Head of Be..." from 12/17/12, 2:00 p.m. - 10:00 p.m. (8 hours). Position Documented as "Head of Be..." from 12/18/12, 7:00 a.m. - 12:00 p.m. (5 hours) Position documented as "Supine" from 12/18/12, 1:00 p.m. - 4:00 p.m. (3 hours). Position documented as "Head of Be..." from 12/18/12, 5:00 p.m. - 12/19/12, 7:00 a.m. (14 hours) Position documented as "Side Right" from 12/20/12, 12:00 a.m. - 8:00 a.m. (8 hours).

A second place the patients' position could be documented was in the "Activities of Daily Living ADL Group-Positioning", section of the electronic record. A review of these documents revealed the following: the patient's position was documented as "Supine" from 12/17/12, 7:20 p.m. - 12/19/12, 7:00 a.m. (34 hours), next documentation of the patient's position was 12/19/12 at 7:00 p.m. which was "right side."

f) On 12/20/12 at 9:30 a.m. an observation of Sample Patient #20 was conducted. The Patient was lying on his/her left side. S/he had no complaints when asked by the Surveyor, and stated that s/he had been turned. Staff Member #1 the patient's nurse was present, and asked by a Surveyor to see the documentation regarding turns. Staff Member #1 stated that s/he had not documented the fact that s/he had placed the patient on his/her left side when s/he started his/her shift at 7:00 a.m. Staff Member #1 did state that s/he would not wait until the end of his/her shift to document turning a patient unless it was a dire situation.