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Based on interview and record review the hospital failed to ensure a wound care consult, accurate assessment and documentation was completed for 1 of 2 patients reviewed [Patient #1] with a pressure ulcer to the coccyx.

Findings included:

The hospital discharge summary reflected Patient #1 was admitted 01/2/10 and discharged to a Rehab hospital on 01/12/10. Patient #1's medical diagnosis was, "Staph Bacteremia, Acute Renal Insufficiency, Right Leg Swelling, Questionable Cellulitis, History of Peripheral Vascular Disease Status Post Right Femoral Pop Bypass, Insulin Dependent Diabetes Mellitis, Depression, Hypertension, History of Coronary Artery Disease, Hyponatremia, History of Paroxysmal Atrial Fibrillation Resolved, Immobility, Mild Confusion and Dementia and Altered Mental Status." The summary made no mention of a pressure ulcer to Patient #1's coccyx.

Between 01/2/10 and 01/7/10 the nurse's notes demonstrated a Braden Score ranging from low to high risk for potential skin impairment. The nurse's note did not indicate any skin impairment was found until 01/8/10 timed at 7:52 which relected, "skin integrity...pressure ulcer." The 01/10/10 and 01/11/10 nurse's notes included the need for a wound care consult; however, the consult was not completed.

The 01/7/10 physician communication order reflected, "?DTI [Deep Tissue Injury] breakdown to bilateral buttocks...apply Xenaderm twice daily and prn [as needed] to buttocks, turn q [every] 2 [[two] hours."

A wound care flow sheet dated 01/10/10 reflected, "wound #1, left buttock, skin tear...size 8.5 x 9.5...scant drainage, purulent, serosanguineous...xenaderm...wound #2, right buttock, skin tear...4 x 4...scant drainage, purulent, serosanguineous...xenaderm..." It should be noted no wound record was found for the 01/7/10 physician order above, nor any documentation indicating a wound care consult was completed for Patient #1.

Hospital B's History and Physical dated 01/12/10 reflected, "decubitus ulcer on the sacrococcyx area nonstageable....patient was admitted from the medical hospital and plan was...monitoring of decubitus changes in sacrococcyx area and will proceed with daily wound care."

On 03/18/10 at 1:01 PM RN #5 was interviewed. RN #5 was asked to review the medical record for documentation regarding Patient #1's altered skin integrity found on 01/7/10. RN #5 verified no documentation could be found except the 01/10/10 wound record.

On 03/18/10 at 2:00 PM RN #6 was interviewed. RN #6 was asked to review the medical record for documentation indicating Patient #1 had a wound consult completed and/or the skin wound assessment team had evaluated the patient prior to discharge. RN #6 stated no wound evaluation had been completed. RN #6 said the documentation regarding skin tear versus decubitus ulcer was inconsistent. RN #6 was asked by the surveyor the process the nursing staff are to complete when altered skin integrity is found. RN #6 stated the physician and/or the nurse can generate a skin, wound consult.

On 03/18/10 at 3:50 PM RN #9 was asked by the surveyor to review Patient #1's physician orders and wound care record. RN #9 stated the wound care record should of been initiated on 01/7/10 when the altered skin integrity was first found. RN #9 stated the nurses are trained to document and refer to wound care team.

The Policy entitled, "Care-Alteration in Skin/Tissue Integrity Protocol Actual" dated 04/23/08 reflected, "A suspected deep tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment...referrals consult wound care team for any stage III or IV pressure ulcer...deterioration of ulcers or poor response to therapy."