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Based on interview and record review, the facility failed to prevent the worsening of a stage I pressure ulcer in one sampled patient (SP #1) of 11 sampled patients .


The findings include:

Review of the SP #1 Emergency Department triage documentation on 01/16/2014 at 15:41 pm, revealed, that SP #1 was sent from a skilled facility for syncopal episode. The patient was noted to be awake, alert, with a history of dementia. SP#1 was admitted to the facility on 01/16/14 for syncope and subarachnoid bleed. The admission assessment nursing notes dated 01/16/2014 at 22:51 pm revealed a stage I pressure ulcer to the sacrum area.

Nursing Assessments from 01/19/14 at 8:00 AM to 01/22/14 at 8:00 AM showed that the patient had a stage 1 pressure ulcer to the sacrum. The Braden Pressure Ulcer Risk Assessment skin score was reassessed on 01/20/2014, the risk decreased from 15 to 11, and the risk level changed from low to high.

Review of the Nutrition Notes dated 01/28/14 at 12:38 PM noted that there was an Unstageable and stage 1 wounds per chart.


The nursing notes dated 01/29/14 at 2:11 PM reported that there was a picture of SP #1 coccyx ulcer and that a copy was sent in the patient's medical record with the discharge information, and that a dressing to the coccyx for stage I ulcer was changed. Review of the "Photographic Wound Documentation" (picture) dated 01/29/2014 revealed a reddened area, with open areas (skin loss), and with darken areas to the coccyx/buttocks area.


Review of the nursing notes in the hospital record, and the discharge summary revealed that there is no assessments and documentation of any treatments of SP #1 sacral pressure ulcer and of the reddened area, with open areas (skin loss) to the coccyx/buttocks with darken areas to the coccyx/buttocks area.


Further review of the patient's medical record did not show that a consult for wound care was completed and that further treatment suggestions were provided.


Review of the medical record from the Skilled Nursing Facility that SP #1 was discharge/transferred to, also revealed that on 01/29/2014, the SP #1 was admitted with an open wound to the sacral area. The record further noted that the stage of the sacral pressure ulcer as unstageable, and the cm (centimeters) length 8.5 cm X width 8.5 cm X depth 0.2 cm, with 50% granular, and 50% necrotic. The pressure ulcer was also noted to have a moderate amount of sero-sanguineous drainage.


On 08/21/14 at 5:14 PM, the Risk Manager Coordinator stated that the SP#1 sacral wound was not caused by pressure, but from incontinence.

Based on interview and record and policy review, the facility failed to ensure that the medications (Precedex and Haldol) were given as ordered in one (Sampled Patient (SP) #1) of 11 sampled patients.


The findings include:
Review of the facility's policy, "Medication Use-Process,"(reviewed 09/2013) has documented, the nurse will follow the 7 rights for medication administration [right patient, right route, right drug, right amount, right time, right documentation, and the right to refuse treatment].
1. Review of SP#1 medical records showed that on 01/16/14 at 3:32 PM, the patient was received in the (ED) Emergency Department. Nurse ' s Rapid Initial Assessment on 01/16/14 at 3:41 PM stated, sent here for syncopal episode, per facility out for 10-15 min (minutes). Awake, alert, hx (history of) dementia pt trying to climb out of bed.
The Physician Orders dated 01/17/2014 showed Precedex intravenous (IV) 50 ML (milliliter(s) to titrate with a loading dose of 0.1 mcg/kg (micrograms/ per kilograms /per hour). over 10 minutes ( optional and not recommended in hypotension). An Initial rate of 0.2 mcg/kg/hr, and then titrate by 0.1 mcg/ kg/ hr every 15 minutes. Maximum rate of 0.7 mcg/kg/hr every 15 minutes.
Review of the patient's MAR ( Medication Administration Record) dated 01/16/2014 to 01/17/2014 showed that Precedex 200 mcg/50 ml in NS (normal saline) to titrate IV as directed. The comments noted :4 mcg/ml, do not start if HR (Heart Rate) less than 50 and SBP ( systole blood pressure) less than 90.
The order 01/17/2014 at 01/17/2014 showed to titrate the Precedex by 0.1 mcg/kg/hr every 15 minutes to a maximum rate of 0.7 mcg/kg/hr (10.5 ml/hr), and to wean, decreasing by 0.1 mcg/kg/hr every 15 minutes, and that abrupt discontinuation should be avoided.
Review of MAR showed that Precedex was given on 01/17/14 at 2:17 AM. Review of 24 Hour Critical Care Flow sheet showed that on 01/17/14 between 1:00 AM and 3:00 AM the patient received 16 ml of Precedex. Review of the 24 hour Critical Care Flow Sheet (Fluid Balance Sheet) dated 01/17/2014 showed that 8 ml of precedex was given at 01:00 and again at 02:00 am. The ( Vital signs on 01/17/14 at 3:08 AM showed the patient ' s BP was 83/38 mmHg and pulse was 59BPM.
Review of the MAR dated 01/17/2014, and the 24 hour Critical Care Flow Sheet dated 01/17/2014 revealed that there was no documentation showing that the Precedex was weaned, decreasing by 0.1 mcg/kg/hr every 15 minutes, avoiding an abrupt discontinuation.

Further review of the 24 hour Critical Care Flow Sheet dated 01/17/2014 revealed that the precedex was restarted again at 08:00 am until 01/18/2014 at 05:00am. Review of SP#1 vital signs revealed that the patient heart rate decreased to as low as 40 during administration.
There is no documentation that the physician was notified and the precedex was discontinued until 5:00 am on 01/18/2014.
On 08/20/14 at 11:00 AM, the Director of Intensive Care Unit (ICU) stated that Precedex is a continuous drip that is given up to 24 hours. If the patient has agitation, precedex produces a calming effect. The heart rate can go down. On 08/21/14 at 1:43 PM, the Director of ICU stated that, if the patient is bradycardic then we turn Precedex off.
On 08/21/14 at 2:52Pm, Staff F, Registered Nurse (RN), stated that, we use precedex when patients are agitated and uncomfortable. We monitor heart rate, blood pressure, sedation and respiratory rate. We want to keep the heart rate above 60BPM and SBP above 90 to 100. If any of these are below, we stop the drip and call the doctor. We call the doctor if vital signs are jeopardized.


2. SP#1 was admitted to the facility on 01/11/14 with exacerbation of dementia with violent behavior. Physician Order on 01/12/14 at 10:07 AM showed that Haldol 2 mg IV (intravenous) HS PRN (at sleep as needed for moderate agitation) was ordered. Review of Medication Administration Record (MAR) showed that on 01/12/14 at 2:06 PM, 2 mg (milligrams) Haldol was given.