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Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Policy and procedures were developed and implemented for all patients who had pressure ulcers.
*Appropriate nursing monitoring, evaluation, reporting, documentation, and intervention had been done for one of one sampled patient (2) with a hospital acquired pressure ulcer.
*Appropriate nursing monitoring, evaluation, reporting, documentation, and intervention had been done for three of three sampled patients (1, 3, and 4) with a non-hospital acquired pressure ulcer.
*Complete nursing care plans for four of four sampled patients (1, 2, 3, and 4) with pressure ulcers were in place.
*Appropriate nursing assessment, monitoring, and implementation of a nutritional plan had been done for one of one patient (2) at significant nutritional risk.
Findings include:

1. Review of patient 2's entire medical record revealed:
*He had been admitted on 4/3/13 and then he was discharged on 4/12/13.
*His diagnoses had included:
-Hypoxia (critical low oxygen levels).
-Hypotension (low blood pressure).
-Sepsis (infection throughout the body).
*He was unresponsive from 4/3/13 through 4/8/13.
*He had been on intravenous fluids (fluids administered through a persons vein [IV]) of normal saline (salt water solution) at 100 cubic centimeters (cc) per hour from 4/3/13 through 4/11/13.
*On 4/8/13 at 9:58 a.m. the physician had ordered a specialty mattress.
*On 4/11/13 potassium 20 mEq (millequivelant) had been added to his IV normal saline solution.
*From 4/3/13 through 4/9/13 he had only taken ice chips orally.
*He had only taken 25-49% of his meals when he had been able to eat.
*The patient had not been weighed throughout his entire hospitalization.

Review of patient 2's medical-surgical assessments revealed:
*The pressure area had only measured three times during his entire hospitalization from 4/3/13 through 4/12/13.
*The following documentation indicated:
-On 4/4/13 at 9:00 p.m. there was an area on patient 2's coccyx that had measured 0.5 centimeters (cm) by 1 cm.
-The Braden scale (an assessment that predicted pressure ulcers) of eight and nine during his hospitalization which meant the patient was at high risk to have developed a pressure ulcer.
-On 4/6/13 at 3:50 p.m. the area on the coccyx had measured 4 cm by 5 cm and had been described as dusky (dark) purple. No other description.
-On 4/10/13 at 7:17 a.m. the area on the coccyx had been documented as stage II (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed) and open to air. The area measured 10 cm.
-On 4/12/13 at 9:22 a.m. (the day of discharge) the coccyx area was described as a stage II, serosanguinous (bloody and clear) drainage, and had not been measured.
*The documentation for repositioning was inconsistent.
*There was no documentation the registered dietitian had been notified of his high risk to develop pressure ulcers.
*The 4/3/13 physician's history and physical revealed no documentation of a current pressure ulcer.

Review of patient 2's laboratory (lab) values revealed:
*On 4/4/13 the hemoglobin (carries oxygen to the entire body) was 12.3. Normal range was 14 to 18.
-On 4/11/13 the hemoglobin was 12.2.
*On 4/4/13 the platelet count (critical for hemostasis and blood clot formation) was 286. Normal range was 130 to 400.
-On 4/11/13 the platelet count was 56.
*On 4/8/13 there was a basic metabolic panel completed that indicated:
- The potassium level (the effects of potassium would include transmission of nerve impulses, contraction of skeletal, smooth, and cardiac muscles, and the maintenance of fluid balance in the body) was 4.7. Normal range was 3.5 to 5.1.
*On 4/8/13 the following lab values were noted:
-The sodium was high 162 (normal was 137 to 145).
-He continued to receive normal saline (salt solution) IV solution at 100 cc per hour. The sodium (that level was critical to body water distribution, neuromuscular function, and severe imbalance could lead to permanent neurological deficits). Normal range was 137 to 145.
-The potassium level was 3.1 (normal was 3.5 to 5.1).
*On 4/11/13 the following lab values were noted:
-The sodium was high at 150.
-The potassium was low at 3.1.
*On 4/12/13 the potassium was low at 3.

Review of patient 2's 4/12/13 physician's discharge summary revealed there was no documentation of the current pressure ulcer nor any treatment that would have been provided at the time of hospitalization and upon discharge.

Review of the provider's Nursing Service Allocation of Hours from 4/4/13 through 4/11/13 revealed:
*There had been no dietary referrals.
*There was a typed area by the "Must refer to Dietary: Number of current patients with change in nutritional status (may include: developed pressure ulcer, TPN [nutrition administered by IV], medications, etc. [and so forth].
-Those areas were blank.

Interview on 1/8/13 at 1:50 p.m. with registered nurse (RN) C during the above medical record review for patient 2 confirmed:
*The documentation for the pressure ulcer was not complete and thorough.
*The nursing staff should have measured the area on the coccyx every day.
*The nursing staff should have notified the physician regarding his skin issues on his coccyx area.
*The patient should have been repositioned every two hours consistently.
*It should have been documented in the medical record how he had been repositioned.

2. Review of patient 4's entire medical record revealed:
*She had been hospitalized from 4/3/13 through 4/9/13.
*Her diagnoses had included:
-Diabetes.
-Dementia.
-Peripheral vascular disease (PVD) (poor blood circulation in the body especially the lower extremities [legs]).
*She had a current pressure ulcer to her right heel that had measured 5 cm by 5 cm, a right ankle pressure ulcer that had measured 2 cm by 3 cm, and two pressure ulcers to her coccyx area that had not been measured.
*On 4/6/13 the right heel pressure ulcer measured 9 cm by 9 cm.
*There had been no documentation of the measurements of her right ankle pressure ulcer.
*There had been no documentation of the two pressure ulcers noted on her coccyx area.
*The nursing staff had been charting inconsistently regarding a dressing change to the right heel ulcer and the right ankle pressure ulcer.

Further review of the medical record revealed there was no physician's order for the dressing changes.

Review of the 4/6/13 physician's daily progress notes revealed:
*The physician had mentioned patient 4 had an infected heel ulcer had been reported as positive for methicillin resistant staphylococcus aureus (MRSA) (a highly contagious and difficult infection to treat).
*There had been no documentation for the progress or treatment of that area or the other areas that had been described in the nursing assessments.

3. Interview on 1/8/13 at 4:10 p.m. with RN C regarding the above information for patients 2 and 4 revealed:
*There should have been daily measurements on all the pressure ulcers that were identified upon admission and those obtained after admission.
*There should have been on-going assessments of the pressure ulcers throughout the hospitalization.
*The physician should have been notified of those areas that had been identified on admission and throughout the hospitalization.
*The nursing staff should not have been performing dressing changes without a physician's order.
*Upon discharge of the patient there had been no documentation regarding patient 2's pressure ulcer to the accepting facility.

Interview on 1/9/13 at 7:30 a.m. with the chief nursing officer (CNO) regarding patient 2 confirmed:
*From 4/3/13 through 4/8/13 the patient had been unresponsive.
*No oral food, nasogastric tube (a tube inserted into the nose and goes into the stomach for nutrition feedings), or IV nutrition had been given to the patient.
*He had received normal saline per IV for six days at 100 cc per hour.
*There had been no RD assessment done.
*A nurse or the physician could have requested a nutritional assessment by the RD.
*The patient should have been evaluated by the RD.
*There had not been a weight obtained during the entire hospitalization.
*She was unsure why a weight had not been obtained on patient 2. *The nursing judgement should have consisted of obtaining a weight especially since he had not been eating and had been unresponsive.
*There was an alteration in lab values with no appropriate evaluation by the nursing staff or the physician.
*The was no documentation for pressure ulcers on patient 2 and 4's care plan.

Interview on 1/9/13 at 8:15 a.m. with the CNO and director of quality assurance regarding pressure ulcers revealed:
*There was no policy and procedures to have directed the nursing staff in the appropriate care of patients that were at risk on admission or had a current pressure ulcer on admission.
*Patient 2's skin issues had been discussed at an interdisciplinary team meeting, but there had been no follow-up to that discussion.
*There had been no root cause analysis related to the occurrence of the pressure ulcer for patient 2.
-There had been no analysis done for any patients who were at risk for the development of pressure ulcers including patients 1, 2, and 4.
*The hospital did not have a wound care team.
*The hospital did not have a specified wound care nurse.
*There was no policy and procedures to direct the nursing staff in the appropriate care of patients that were at risk or had a current pressure ulcer on admission.




27457

3. Interview and electronic medical record review on 1/8/14 from 11:30 a.m. through 3:30 p.m. with the CNO regarding patient 3's pressure ulcer care revealed:
*He had been admitted on 2/1/13 and discharged from his acute hospital stay on 2/4/13.
*He had been admitted to the hospital for a surgical procedure to a pressure ulcer located on his right buttock.
*He had a medical history of paraplegia (legs did not function) and was wheelchair bound.
*On admission nursing noted his surgical wound on the right buttock and also noted his coccyx (tailbone) area had been "reddened/breakdown."
-No measurement of the wound, description of the wound, treatments for the wound, or physician notification of the reddened broken down area on the coccyx were present in the medical record for the term of his stay.
*The CNO confirmed nursing staff had not properly measured, documented, sought treatment for, and notified the physician of the coccyx wound noted above.
*The CNO confirmed nursing staff had not incorporated his coccyx wound into his nursing plan of care.
*His care plan did not incorporate the wound noted on his coccyx.
*No written pressure ulcer policies and procedures were in place for the hospital.
*They had no wound care team or specialized wound care nurse to address patient's with pressure ulcers.



26180

4. Review of patient 1's medical record 1 revealed:
*He had been admitted on 1/3/14 and remained in the facility throughout this survey.
*He had transferred from another acute care hospital to this facility.
*His presenting problems at admission included diarrhea and nausea.

Review of a 1/2/14 acute wound care document completed by a certified nurse practitioner sent from the transferring hospital revealed "Patient states his "sore bottom" started days ago when he was in the hospital in [name of hospital]. The sacral ulcer appears to be pressure related, The red, raw posterior scrotum, buttocks, and perineum appears to be moisture related/due to frequent loose stools."

Interview on 1/8/14 at 11:15 a.m. with RN A regarding patient 1 revealed:
*He currently had a reddened open area on his coccyx that blanched (became pale when pressure was applied).
*They applied Aloe Vesta to it whenever he went to the bathroom or needed it.
*The Aloe Vesta was what they used on any kind of skin issue like he had.

Review of patient 1's 1/3/14 physician's order revealed:
*Skin integrity: Prevent breakdown: Moisture barrier for incontinence.
*He was to have a specialty bed.
*There was not an order for the treatment of the pressure area on his coccyx.

Review of patient 1's care plan revealed:
*Risk for impaired skin integrity was identified on 1/4/14.
*The approaches included:
-Pressure ulcer prevention.
-Collaborate with Wound Ostomy/skin care team.
*The goal was tissue integrity: skin and mucous membranes.
*It had not been addressed there was a pressure ulcer, only the risk for one.

Review of patient 1's nursing care flowsheet and interview with RN B revealed:
*From 1/3/14 through 1/7/14: "Wound properties: 2 cm (centimeter) oval open area to right coccyx/buttock."
-"Red, but blanches"
*The dressing type was "Open to air and barrier cream."
*There was no information on the exact location of the wound.
*She agreed the documentation was not descriptive of the location on the coccyx.
*There was no documentation of the nurses informing the physician of the status of his pressure ulcer.

Review of patient 1's physician's daily progress notes revealed:
*The physician had seen him daily from 1/3/14 through 1/7/14.
*The physician had not addressed the pressure area on his coccyx in his progress notes.
*On 1/7/14 the physician wrote "His perineum appears to be less sore."
-It had not specified what area he was assessing and if that included any pressure areas or only areas that were affected by incontinence.
-It had not specified if that assessment was based on observation of the patient's perineal area, on interview with the patient, or information given from the nurse.

Observation on 1/8/14 at 2:15 p.m. by RN surveyor 27457 of patient 1's pressure ulcer revealed:
*He had a full skin thickness, unstageable pressure ulcer covered with yellow eschar on his right coccyx. Surrounding the unstageable ulcer was a large stage 1 pressure ulcer.
*No measurements were taken at the time of this observation.
*The unidentified RN who accompanied surveyor 27457 applied barrier cream directly into the bed of the unstageable wound during the observation.

Review of the manufacturer's recommendations for the barrier cream that had been applied to patient 1's coccyx revealed "Do no use on deep or puncture wounds."

Interview on 1/9/14 at 7:45 a.m. with RN A revealed:
*They did not have a protocol that stated when to use the Aloe Vesta barrier cream.
-That was all they used.
*She had not staged patient 1's pressure ulcer.
*The nurse on duty when he was admitted had staged it as a stage II pressure ulcer.
*She assumed the physician had looked at the patient's coccyx and pressure area, because the nurse had charted on it.
*She was unaware the physician had not documented on the patient's pressure area.
*They did not have a skin care team.

Review of the provider's 11/26/12 Documentation policy revealed:
*"The purpose of the policy is:
-To establish a standard of practice for documentation that will be adhered to by all nurses, assistive staff, and interdiscipline team members, as appropriate, who provide care to patients."
-To recognize the purpose of the medical record is that it is to serve as the legal recording of the patient's experience while under the care of the health care providers at [the name of the facility].
-To reflect the individualized care that is provided to all patients.
*Charting by Exception is a multifaceted approach to planning and documenting patient care in which significant findings and exception to clinical norms are charted. Deviations from normal assessment parameters, from normal responses to treatments and protocols, or from the individualized plan of care and expected outcomes are to be documented.
*Documentation is to reflect the patient's response to care provided.
*All assessments and reassessments will be documented and timed in the patient's medical record. A nurse will assess each patient at least once per shift and document the findings. Other providers would document as indicated.
*A comprehensive assessment is to be completed upon inpatient admission to the hospital.
*The Plan of Care is to be initiated within the first 24 hours and updated throughout the stay as needed. The interdisciplinary Team (IDT) members consulted will update the Plan of Care within 24 hours of the first visit when an IDT problem is identified.
*The Plan of Care will be updated as patient status changes and as plans or goals changes.
*Members of the interdisciplinary team will contribute to the Plan of Care to assist with individualized interventions and communication as appropriate.
*All members of the IDT will document specific continued care needs."

Review of the provider's April 2011 Nutritional Screening for Patients policy revealed the policy was to have provided a uniform procedure for screening patients for nutritional risk upon admission.

Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, pp. 1189 through 1192, revealed:
*"Pressure ulcers have multiple etiological factors. Assessment for pressure ulcer risk incudes using appropriate predictive measure and assessing a patient's mobility, nutrition, presence of body fluids, and comfort level.
*On admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities, assess individuals for risk of pressure ulcers development. Perform pressure ulcer risk assessment systematically.
*Assessment includes documenting the level of mobility and the potential effects of impaired mobility on skin integrity.
*An assessment of the patients' nutritional status in an integral part of the intimal assessment data for patients at risk for impaired skin integrity and wound. Malnutrition is a risk factor for pressure ulcer development.
*Continual exposure of the skin to body fluids increases a patients' risk for skin breakdown and pressure ulcer formation.
*A nurse often assesses wounds under two conditions: at the time of injury before treatment and after therapy, when the would is relatively stable.
*Assessment revealed clusters of data to indicate whether an actual or a risk for impaired skin integrity exists.
*After identifying nursing diagnoses, develop a plan of care for a patient who has actual or is at risk for impaired skin integrity.
*Critical thinking ensures that a patient's plan of care integrates all that you know about the individual and key critical thinking elements. Professional standards are especially important to consider when you develop a plan of care."

Based on record review, interview, and policy review, the provider failed to ensure an effective quality assurance process and measures were in place to evaluate appropriate prevention of and care of four of four sampled patients (1, 2, 3 and 4) with pressure ulcers. Findings include:

1. Interview on 1/9/14 at 8:15 a.m. with the chief nursing officer and the quality assurance director regarding patient 2 revealed:
*They were aware of that patient, because he had been re-admitted back and forth between the nursing home and the hospital.
*The staff in the nursing home had discussed him in the hospital/nursing home interdisciplinary team meeting, because he had a pressure ulcer.
*They had not discussed him further in the hospital even though the pressure ulcer had developed in their hospital.
*From a quality assurance perspective there had been no further discussion of:
-His pressure ulcer had actually developed in the hospital.
-Other patients with pressure ulcers that had developed in the hospital.
-A review of the facility policies and procedures regarding pressure ulcer prevention and care.
*They were unaware there were no policies and procedures for pressure ulcers.
*They had not used the tracking tools available in the electronic medical record to identify pressure ulcers as a focus area for improvement.
*They did not have any quality assurance project looking at pressure ulcer prevention.
*They had not had a team that focused on skin issues with patients for a couple of years but thought they needed one.
*They agreed there should have been a focus on pressure sore prevention and treatment in their quality assurance program.
Refer to C271, finding 1.

Review of the provider's 9/1/02 Quality Management/Improvement plan revealed:
*"[Name of provider] has a legal and moral obligation to provide its patients and residents with a level of care consistent with recognized professional standards, to deliver care in a cost-effective manner within available resources, and to provide and maintain a safe patient and resident environment.
*A coordinated, systematic, multi-disciplining facility-wide approach will be followed to improve resident and patient care and health outcomes."
*The outcomes included:
-"Improve the processes and outcomes of patient and resident care and treatment systematically and collaboratively.
-Minimize the probability of events that have an adverse physical or psychological effect on patients, residents, visitors and staff.
*The approach included:
-Collaborate across disciplines and departments to identify and prioritize important areas for improvement based on organizational goals and reflecting high risk, high volume, or problem prone issues.
*A performance improvement (PI) work-plan is developed annually and includes a schedule of activities, objectives, scope and projects for the year, as well as planned monitoring of previously identified issues including tracking over time.
*The PI/RM (risk management) committee and performance improvement/risk management coordinator shall have access to and review data sources to identify problems or areas for study. These sources shall include:
-Minutes of team meetings.
-Minutes of committee meetings.
-Patient and resident records.