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Based on staff interviews, clinical record review and review of the facility's Policies and Procedures, the facility failed to ensure the nursing staff develop and kept current a nursing care plan to manage identified risk factors for Patient #1 developing a Pressure ulcer. The nursing staff also failed to ensure a wound care assessment was done by the certified wound care nurse as per physician's order. These failures affected 1 of 10 sampled patients (#1) who had altered skin integrity.

Findings include:

Clinical record review revealed Patient #1 was admitted to the facility via emergency transport from an Assisted Living Facility on 02/02/2015. Patient #1 arrived at Florida Medical Center-A Campus of North Shore Emergency Department (ED) on 02/02/2015 at approximately 9:00 AM. The patient was triaged at 9:11 AM by the nursing staff. A nursing assessment was completed at 9:36 AM including an "Adult Tissue Integrity Screening"; Scoring was completed as per the Braden Scale for predicting pressure sore risk. The score for Patient #1 in the ED of the facility, was 17, which indicates a mild risk for pressure wounds. The documented ED skin assessment reveal,"skin is fragile, is thin, has skin tears on left elbow and ecchymotic areas on both arms." At 2:25 PM on 02/02/2015 Patient #1 was admitted to the hospital, and transferred to a room on the medical/surgical unit (3rd floor) on at 10:50 PM.

Review of Patient #1 medical record revealed the following:
02/02/2015 at 5:55 PM- physician ordered nursing wound consult
02/04/2015 at 4:08 PM- system ordered wound consult related to Braden Assessment documentation (Score 11- indicates high risk for pressure sore)
Further review, of the medical record for Patient #1, did not reveal any documented visits by wound care nurse / consultant as ordered by the physician. Throughout the inpatient stay at the facility, Braden scale assessments were completed by registered nurses as follows:
02/02/2015- 10:00 PM- 19 (mild risk)
02/02/2015- 11:00 PM- 15 (mild risk)
02/03/2015- 8:33 AM- incomplete
02/04/2015- 4:42 AM- 13 (high risk)
02/04/2015- 2:09 PM- 11 (high risk)
02/04/2015- 10:00 PM-11 (high risk)- indicates Stage 1 redness to sacrum
02/05/2015-8:35 AM- 14 (high risk)- indicates Stage 1 redness to sacrum
02/05/2015- 9:24 PM- 17 (moderate risk)- no further documentation
02/06/2015- 1:00 AM- no assessment, redness to sacrum , Stage 1
02/06/2015- 9:25 AM- 14 (high risk) , Excoriation to sacrum, Stage 2

Interview with the wound care nurse (RN#C) on 03/27/2015 at 11:30 AM revealed, "wound care is automatically triggered in the electronic / computer system based on Braden Scale Assessment results; the results of the Braden Scale Assessment in turn triggers the physician to write / sign an order for care/treatment. The wound care consultant nurse is expected, per procedure, to obtain the doctors order from the electronic system. The nurse admitted not accessing / acknowledging the electronic system andcompleting a consult as per the physician orders dated 02/02/2015 at 5:55 PM.

Physicians Discharge Summary dated 02/06/2015 documents,"The patient developed a stage II ulcer (broken blister) of the coccygeal area while in the hospital."

A review of the Interdisciplinary Care Plans for Patient #1, dated 02/02-02/06/2015, disclosed no Care Plans for altered skin integrity, no interventions/approaches, and no goals related to skin integrity.

Review of the facility's Policies and Procedures titled, "Skin Integrity Assessment & Protocol for Pressure Ulcer Prevention and Impaired Skin" revealed:
"if impairment in skin integrity is found during the patient's hospitalization, then a photo will be taken of impaired areas and noted in the record. A wound care consult will be initiated and physician informed.
The primary nurse will implement the initial treatment per the protocol listed in section 8 of this policy for all wounds.
Section 8:
Pressure redistribution
monitor hydration
monitor nutritional intake
manage incontinence- consider incontinence skin barrier
proper hygiene"

During an interview conducted with the certified wound care nurse, RN #C on 03/27/2015 at 11:30 AM, RN #C provided the following information, "There are 2 certified wound care nurses in the facility. We follow Braden scale and use score care for every patient, this begins in the ED on admission. A score of 18 or below triggers a wound care consult and order. We try to see the patients as soon as possible but at least within 24 hours. Patients are seen per priority, actual wounds take priority. After I see patients, I do a care plan or update/add to the existing care plan. I also make sure the nurse is aware of the treatment plan, and will educate and remind. Patient #1 was not seen by wound care while she was in the hospital."

RN #1, the unit manager, stated in an interview on 3/27/2015 at 10:15 AM,"The care plans are located on the clipboards with the patient's chart. Any member of the Interdisciplinary Team can initiate or add to the Care Plans. The staff use the Care Plans to make decisions regarding patient care. I reviewed the medical record of Patient #1 and there is no care plan related to skin or pressure areas of the sacrum. The documentation does not indicate whether routine measures were put in place as per policy. We have documentation of barrier cream but I cannot see any other interventions documented."

During an interview with the Chief Nursing Officer (CNO) on 03/30/2015 at 10:30 AM, the CNO stated,"The documentation in this record is lacking, I am working on some education and processes to correct these issues."
.

Based on staff interviews, clinical record review and review of the facility's Policies and Procedures, the facility failed to ensure the nursing staff develop and kept current a nursing care plan to manage identified risk factors for Patient #1 developing a Pressure ulcer. The nursing staff also failed to ensure a wound care assessment was done by the certified wound care nurse as per physician's order. These failures affected 1 of 10 sampled patients (#1) who had altered skin integrity.

Findings include:

Clinical record review revealed Patient #1 was admitted to the facility via emergency transport from an Assisted Living Facility on 02/02/2015. Patient #1 arrived at Florida Medical Center-A Campus of North Shore Emergency Department (ED) on 02/02/2015 at approximately 9:00 AM. The patient was triaged at 9:11 AM by the nursing staff. A nursing assessment was completed at 9:36 AM including an "Adult Tissue Integrity Screening"; Scoring was completed as per the Braden Scale for predicting pressure sore risk. The score for Patient #1 in the ED of the facility, was 17, which indicates a mild risk for pressure wounds. The documented ED skin assessment reveal,"skin is fragile, is thin, has skin tears on left elbow and ecchymotic areas on both arms." At 2:25 PM on 02/02/2015 Patient #1 was admitted to the hospital, and transferred to a room on the medical/surgical unit (3rd floor) on at 10:50 PM.

Review of Patient #1 medical record revealed the following:
02/02/2015 at 5:55 PM- physician ordered nursing wound consult
02/04/2015 at 4:08 PM- system ordered wound consult related to Braden Assessment documentation (Score 11- indicates high risk for pressure sore)
Further review, of the medical record for Patient #1, did not reveal any documented visits by wound care nurse / consultant as ordered by the physician. Throughout the inpatient stay at the facility, Braden scale assessments were completed by registered nurses as follows:
02/02/2015- 10:00 PM- 19 (mild risk)
02/02/2015- 11:00 PM- 15 (mild risk)
02/03/2015- 8:33 AM- incomplete
02/04/2015- 4:42 AM- 13 (high risk)
02/04/2015- 2:09 PM- 11 (high risk)
02/04/2015- 10:00 PM-11 (high risk)- indicates Stage 1 redness to sacrum
02/05/2015-8:35 AM- 14 (high risk)- indicates Stage 1 redness to sacrum
02/05/2015- 9:24 PM- 17 (moderate risk)- no further documentation
02/06/2015- 1:00 AM- no assessment, redness to sacrum , Stage 1
02/06/2015- 9:25 AM- 14 (high risk) , Excoriation to sacrum, Stage 2

Interview with the wound care nurse (RN#C) on 03/27/2015 at 11:30 AM revealed, "wound care is automatically triggered in the electronic / computer system based on Braden Scale Assessment results; the results of the Braden Scale Assessment in turn triggers the physician to write / sign an order for care/treatment. The wound care consultant nurse is expected, per procedure, to obtain the doctors order from the electronic system. The nurse admitted not accessing / acknowledging the electronic system andcompleting a consult as per the physician orders dated 02/02/2015 at 5:55 PM.

Physicians Discharge Summary dated 02/06/2015 documents,"The patient developed a stage II ulcer (broken blister) of the coccygeal area while in the hospital."

A review of the Interdisciplinary Care Plans for Patient #1, dated 02/02-02/06/2015, disclosed no Care Plans for altered skin integrity, no interventions/approaches, and no goals related to skin integrity.

Review of the facility's Policies and Procedures titled, "Skin Integrity Assessment & Protocol for Pressure Ulcer Prevention and Impaired Skin" revealed:
"if impairment in skin integrity is found during the patient's hospitalization, then a photo will be taken of impaired areas and noted in the record. A wound care consult will be initiated and physician informed.
The primary nurse will implement the initial treatment per the protocol listed in section 8 of this policy for all wounds.
Section 8:
Pressure redistribution
monitor hydration
monitor nutritional intake
manage incontinence- consider incontinence skin barrier
proper hygiene"

During an interview conducted with the certified wound care nurse, RN #C on 03/27/2015 at 11:30 AM, RN #C provided the following information, "There are 2 certified wound care nurses in the facility. We follow Braden scale and use score care for every patient, this begins in the ED on admission. A score of 18 or below triggers a wound care consult and order. We try to see the patients as soon as possible but at least within 24 hours. Patients are seen per priority, actual wounds take priority. After I see patients, I do a care plan or update/add to the existing care plan. I also make sure the nurse is aware of the treatment plan, and will educate and remind. Patient #1 was not seen by wound care while she was in the hospital."

RN #1, the unit manager, stated in an interview on 3/27/2015 at 10:15 AM,"The care plans are located on the clipboards with the patient's chart. Any member of the Interdisciplinary Team can initiate or add to the Care Plans. The staff use the Care Plans to make decisions regarding patient care. I reviewed the medical record of Patient #1 and there is no care plan related to skin or pressure areas of the sacrum. The documentation does not indicate whether routine measures were put in place as per policy. We have documentation of barrier cream but I cannot see any other interventions documented."

During an interview with the Chief Nursing Officer (CNO) on 03/30/2015 at 10:30 AM, the CNO stated,"The documentation in this record is lacking, I am working on some education and processes to correct these issues."
.