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Based on record review and interview the facility failed to provide nursing care as needed to prevent the development of pressure wounds for 1 (#1) of 25 patients sampled. The failure to provide nursing care to prevent pressure wounds can lead to patient discomfort and increased complications.

Findings:

Record review of the facility provided policy entitled "Alteration of Skin Integrity" dated 8/92 with a review date of 8/2008 reveals that the facilities policy is that all patients are covered by the policy upon admission and that "skin/wound alteration will be assessed at the time of identification, at each dressing change, and with any change in status."

Review of the facility ' s policy entitled, "Wound assessment and photography" dated 8/08 with no review date reveals that photographic documentation will be done upon identifying hospital acquired pressure ulcers and any wound that will require dressing changes by the nursing staff and upon discharge from the facility.

Review of patient #1 ' s medical record revealed a Nursing Progress Note dated 06/25/09 at 11:30 AM which indicates that the patient was turned side to side. Further review of this note revealed, " air mattress to bed [right] buttock excoriated, Balmex cream applied. " Another entry on this same date at 2000 (8 PM) revealed the patient ' s buttocks was still red. Review of the nursing note dated 6/25/2009 at 18:00 (6:00 PM) reveals that a wound consult was ordered.

Review of the wound consult dated 6/26/2009 at 4:15 PM reveals that the patient had bilateral dry abraded red skin and that the wound will be covered with a silicone foam dressing. Further review of the consult revealed there were no open areas and the area measured 3 centimeter (cm) x 1 cm in size. Further review of this record, failed to reveal any photographs of the patient's pressure sore.

Review of the order dated 6/26/2009 at 4:50 reveals that a dressing change is ordered every 3-5 days and PRN.

During interview with the wound care nurse on 2/2/2010 at 10:30 AM she stated that pictures of the wound were not taken. She also stated that she had ordered a silicone, foam dressing to be changed by the nursing staff.

Review of the patient ' s admission assessment after transfer to another facility, dated 06/27/09, reveals that the patient had wounds on the buttocks that were identified as stage II pressure ulcers.

Wound assessment dated 6/29/2009 and completed at the receiving facility indicates two stage II pressure wounds, both measuring 3 cm length, 2 cm width and 0.1cm depth on the patient's buttocks.

Based on record review, and interview, the facility failed to ensure that 4 (#9, #12, #14, and #1) of 25 patients sampled had their discharge summaries completed within 30 days of discharge. Failure to record discharge information, may lead to misinformation for the continuity of care.

The Findings Include:

1. Record review for patient #9, revealed an admission date of 6/17/09 and a discharge date of 6/20/09. The discharge summary was dictated on 8/12/09.

2. Record review for patient #12, revealed an admission date of 8/25/09 and a discharge date of 8/28/09.
The discharge summary was dictated on 10/6/09.

3. Record review for patient #14, revealed an admission date of 6/17/09 and a discharge date of 6/20/09. The discharge summary was dictated on 8/26/09.

4. Record review for patient #1, revealed an admission date of 6/17/09 and a discharge date of 6/27/09. The discharge summary was dictated on 8/31/09.

Review of the facility policy revealed that "all medical records shall be completed within 30 calender days after discharge.

Interview with the Director of Quality Management on 2/1/10 at 11 AM, revealed that the discharge summaries are to be completed on or before 30 days after discharge.