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Based on record review, observation, and interview the facility failed to have a consistent process for evaluating, treating, documenting, and monitoring pressure ulcers for 4 of 10 sampled patients (3 closed records and 1 active record). This created a risk for ineffective wound treatment. Findings:

Patient #1

Record review on 4/21-22/11 and 5/ 18/11, revealed Patient #1 was admitted to the facility on 3/29/11 with diagnoses that included respiratory failure and morbid obesity.

Review of the initial nursing assessment, dated 3/29/11 at 10:20 pm, revealed nurses were "unable to assess the back due to morbid obesity."

Further review of the nursing assessment revealed the Patient's Braden Score (methodology used to predict pressure ulcer risk) totaled 7 "Score >18 initiate Pressure Ulcer Protocol " which placed the Patient at high risk for pressure ulcers.

During an interview on 4/21/11 at 2:00 pm, RN #4 confirmed that Patient # 1 had developed pressure ulcers during his stay at the hospital. The RN stated the pressure wounds were a stage "II pushing a III" and the Patient had tunneling from the buttocks to the scrotum (area above the buttocks). RN #4 then confirmed the documentation for the wounds was located in the nursing chart cards and in the progress notes. The RN showed the surveyor a plastic card handing from her nametag that listed a guide for staging a wound and for using the Braden score.

During observation of morning care on 4/22/11 at 8:15 am, the Patient was being turned to his side. A disconnected "dignity" tube (tube used to drain feces from immobile patients) was lying under the patient and the bedding was soiled with feces. There was an open Y shaped wound on the Patient's sacrum (lower backside) with undermining on the left side of the wound and undermining and tunneling on the right. There was also an open wound on the Patient's right buttock, and two open wounds around the Patient's rectum.

During an interview on 4/22/11 at 8:20 am, when asked how the tunneling to the wound was measured, RN # 4 responded, "I've never stuck my finger in it."

Further review of the nurse's notes revealed the following entries:

4/2/11 at 11:30 am, "Redness to buttocks";

4/5/11 at 4:20 am, "Skin buttocks reddened";

4/6/11 at 10:30 am, "R buttocks with x [times] 3 mm round wound that is bleeding";

4/8/11 at 7:00 am, "skin tear on buttock R [right]";

4/11/11 at 7:00 pm, "Sacrum stage II";

4/12/11 at 7:00 pm, "Sacrum stage II";

4/14/11 at 11:30 am, "Deep bloody ulcers x [times] 2 on buttocks";

4/15/11 at 7:15 am, "Stage 2-3 Decub [decubitis] x 2 mid buttocks in fold crease [and] 3 cm [centimeter] R buttock";

4/17/11 at 5:00-6:00 pm, "Wound is fissured in peri crack and is like a Y. Very moist when dressing removed. Other circular wound R [right] is vascular but area around wound feels hard/firm. Wound vesicular. OTA [open to air] Granulation tissue is 'Y' crack wound";

4/17/11 at 1:20 pm, "...dressing to coccyx looks soiled will remove";

4/18/11 at 11:00 am, "breakdown R stage II bleeding. Deep stage II skin firm with cap [capillary] refill > 3 sec [seconds] skin dusky. Stage II breakdown around rectum";

4/20/11 at 10:00 am, Described sacrum "...Deep stage II 1 cm [centimeter] deep @ [at] tunnel, skin around dusky firm", right buttock breakdown "stage II" and the rectum "stage II around rectum";

4/21/11 at 8:00 pm, "Sacral stage III mid back R [right] to L [left] flank 1 inch stage II"; and

4/22/11 at 7:00 am, "open stage 2-3 wounds w/a [with a] tunnel."

The medical record contained no documentation of the size or depth of the sacral "Y" shaped wound or the wounds around the rectum.

During an interview on 4/22/11 at 1:45-2:15 pm, RN #s 1 and 5 confirmed that measurements and wound staging was inconsistent. When asked about down staging a wound they replied it was to show the healing of the wound.

During an interview on 4/22/11 at 3:45 pm, when asked about measurements and staging of a wound, the facility's Wound Care Nurse stated if she was following a particular Patient's wound care she measured the wound weekly. The Wound Care Nurse confirmed the stage of a wound would never change and wounds should not be staged between the numbers (between a 2-3).

Patient #2

Record review revealed Patient #2 was admitted 12/12/10 to the critical care unit with diagnoses that included sepsis and a Stage II decubitus ulcer on his coccyx. Review of the 12/12/11 nursing care sheet revealed the wound was documented as "Stage II-III coccyx ulcer" . Further record review revealed no wound consultation was ordered and no measurements were done.

During an interview with RN #1 on 5/18/11 at 1:30 pm it was confirmed there was no wound consult ordered for Patient #2 and no measurements of Patient #2's wounds had been completed.

Patient #3

Record review on revealed Patient #3 was admitted to the medical unit on 12/1/10 with diagnoses that included sacral and ischial pressure ulcers and paraplegia.

Review of the admission assessment, dated 12/1/10, revealed Patient #3 had 3 pressure ulcers on coccyx and right buttocks. The patient's history and physical of 12/1/10 revealed the Patient was admitted with "open stage IV wounds of the ischium bilaterally and the sacrum with some pink granulation tissue within each wound. Scant amount of thick white discharge coming from the left ischial wound which appears to track to bone." Further review of the history and physical revealed, "We will involve the Wound Consult Service to help in management..."

During an interview on 4/22/11 at 1:50 pm, RN #2 confirmed there was no record of the Wound Care RN seeing the patient and no measurements were or had been taken of the wound during the Patient's stay at the facility.

Further record review revealed that, until 12/8/10 at 3:45 pm when the Wound RN did wound teaching to the family, there was no documentation the Wound RN had been consulted regarding the Patient's wounds.

Patient #4

Record review on 4/22/11 revealed Patient #4 was admitted to the medical unit on 2/9/11 with diagnoses that included weakness. A history and physical, dated 2/9/11, documented the Patient had sacral decubitus ulcer on admission, "Notable for around a 5 x 5 cm stage 2 sacral decubitus ulcer..." A wound consult was ordered on 2/13/11. Review of the "ANMC Adult Inpatient Acute Care Daily Flowsheet" revealed the Patient had a "Stage III Decub." Patient #4 was discharged to home with Home Health services, which included wound therapy. Further record review revealed no documentation of wound measurements or sizing from 2/10/11-2/14/11. During an interview on 5/18/11 at 1:35 pm, RN #1 confirmed that the Patient did not have any wound measurements or sizing during the hospital stay and was discharged with a stage III decubitus ulcer.

During an interview with the Wound Care RN on 4/22/11 at 3:45 pm, she stated she did not see Patient #4, as she was out of town during the Patient's hospital stay.

During an interview on 5/18/11 at 1:15 pm with RN #s 1 and 3, they stated the facility uses the "Guidelines for Staging of Pressure Ulcers" and the "Wound Assessment Checklist". RN #3 added that nurses should contact the Wound Care RN if they have questions about patients' pressure ulcers.

Review of the "Wound Assessment Checklist" revealed guidelines for documenting the following: location; size; dressing used; stage; pressure redistribution; nutritional assessment; drainage (amount/color/odor); viable tissue in wound; and undermining/tunneling.