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Based on interview and record review the Hospital failed to send a complainant a letter acknowledging their grievance per the Hospital's policy. (Patient ID# 1)

Findings include:

Interview 11/27/12 at 8:30 a.m. with the Chief Nursing Officer (CNO) revealed she was aware of a complaint regarding patient ID# 1. The CNO stated that patient ID# 1's daughter made a complaint 10/31/12 about her Father ' s heels being " soft and mushy " once he arrived on the Rehabilitation Unit from the Intermediate Medical Intensive Care Unit (IMU). The patient had a history of diabetes, poor circulation and loss of one toe.

Record review of a policy titled " Patient / Family Complaint " dated 10/2010 stated " A patient grievance is a written or verbal complaint by a patient, or the patient ' s representative, regarding the patient ' s care, abuse or neglect, issues related to the hospital ' s compliance with the CMS Hospital Conditions of Participation. Procedure: Patient Advocate is responsible for: Initial response will include an acknowledgement of the complaint and will indicate that review has been initiated. Initial response letter will be mailed within seven working days of the alleged incident by the Quality Management Office. "

The Quality Assurance Director (ID# 2) acknowledged 11/27/12 at 2:50 p.m. that the complainant should have been sent a letter from the hospital within 7 days acknowledging her complaint. The hospital inadvertently failed to send the 7 day letter.

Based on interview and record review the nursing staff failed to supervise patient care in 3 of 3 patient records reviewed on the Intensive Medical Care Unit (IMU). Records reviewed failed to:
1) Document measurements of pressure ulcers per facility policy,
2) Obtain physician orders for pressure ulcer treatments,
3) Accurately perform Braden skin risk assessment

(Patient ID#'s 1, 2, 3)

Findings include:

Record review of a policy titled " Skin Care Assessment " dated 6/13/11 stated: " Purpose: to describe the process and documentation format for wound and skin assessment. Procedure: The Risk Assessment is completed based on criteria including sensory, perception, moisture, activity, mobility, nutrition, and friction and sheering. (If the score is 16 or less, the patient may be at risk for impaired skin integrity) ........ Document wound measurements one time per week ... "

PATIENT ID# 1
Record review of the medical record for patient ID# 1 revealed he was admitted to the hospital 10/10/12 and discharged on 11/7/12.

A History and Physical dated 10/10/12 stated " A 72-year-old male presented with severe shortness of breath, and orthopnea..He was found to have decompensated systolic congestive heart failure as well as evidence of acute MI. Past Medical History: Hypertension, COPD, Hyperlipidemia, Diabetes, Poor compliance, Peripheral neuropathy, Peripheral arterial disease, bilateral pneumonia ...Past Surgical History: Left fifth toe amputation. Plan of Treatment: The patient is being admitted to the hospital for cardiovascular surgeon evaluation. "

Record review of a Cardiovascular Surgeon evaluation dated 10/11/12 stated " ....Extremities: I am unable to palpate pulses in either foot .... " Preparation for open heart surgery ....

The nursing staff used a Braden Risk Assessment for patient ID# 1 on 10/11/12 to evaluate the risk of developing pressure ulcers and the patient was scored at " 20 " or no risk of developing pressure ulcers. (According to the Hospital ' s Skin Care Assessment policy only a score of 16 or less is at risk).

The patient had open heart surgery and was transferred to the Intensive Medical Care Unit (IMU). The patient had no skin problems upon admission 10/10/12 according to the nursing shift assessments.
Nursing shift assessments noted Erythema (redness) to buttocks bilaterally beginning 10/15/12 while on the IMU unit. The Nursing assessments failed to document any problems with the patient's heels while in IMU. No measurements were taken of the redness to the buttocks bilaterally. No heel protectors nor a pressure relieving mattress was ordered by the physician.

Patient ID# 1 was transferred 10/25/12 from the IMU unit to the Rehabilitation Unit on the first floor.
The nursing admission assessment on the Rehabilitation Unit noted " Erythema (Redness) to buttocks bilaterally, Left lower extremity monitoring due to bruise and Left foot heels erythema." No measurements were taken of the redness to the buttocks or the patients heels.

On 10/29/12 the nursing assessment noted "closed blister bilateral feet." Preventative boots were provided to the patient. No measurements were documented of the patient's heels.

On 10/30/12 the nursing assessment noted " Scabs bilateral heels, Bruise and closed blister on right foot and Left foot closed blister. No measurements were documented of the patient's heels.

On 10/31/12 the nursing assessment noted " Closed blister bilateral heels and Erythema to bilateral buttocks. " No measurements were documented.

On 11/4/12 the nursing assessment noted " Skin tear right buttock and erythema bilateral buttocks, Bilateral heels blister open. " No measurements were documented.

On 11/6/12 the nursing assessment noted " Left heel open blister and 4x4 and ace bandage. No measurements were documented and no physician order was obtained for the 4x4 and ace bandage. The Right heel open blister was not noted. No measurements were documented.

On 11/7/12 the nursing assessment noted " Left heel open blister and 4x4 and ace bandage." The Right heel open blister was not noted. No measurements were documented of the patient's blisters. The patient was discharged 11/7/12 to a Rehabilitation Hospital.

The Quality Assurance Director acknowledged 11/27/12 at 2:50 p.m. that no measurements were documented of patient ID# 1's pressure ulcers. The Director further stated that nursing staff should have measured the patient's pressure ulcers according to hospital policy.


PATIENT ID# 2
Record review of the History and Physical revealed this 71- year- old patient was admitted to the hospital 11/22/12 with increased confusion and could not move his right side. The patient had a history of coronary artery disease, hypertension, hyperlipidemia and diabetes.

Initial nursing assessments on 11/22/12 revealed no skin problems. Nursing assessments on 11/27/12 documented Stage II pressure sore on the high back, Stage II on the left thigh, and Stage I on the coccyx. The nurse applied Dueoderm to the coccyx with no physician order and no measurements were documented of the pressure ulcers.

PATIENT ID# 3
Record review of the History and Physical revealed this 79-year-old patient was admitted on 11/13/12 for elective redo of a total hip replacement. The patient had a tracheotomy that resulted from previous history of head and neck cancer.

Initial nursing assessments on 11/13/12 revealed no skin problems Nursing assessments on 11/18/12 revealed a Stage I pressure sore on the buttocks. No measurements were documented.