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Based on observations, interviews, and record reviews, the patients was not free from all forms of abuse (neglect). The hospital did not ensure that proper protocols and preventive procedures were in place so that bedridden patients did not develop skin break downs while they were in the hospital. Three (3) out of five (5) patients reviewed did have a skin break down while they were a patient in the hospital. Patient number #1, 2, 5 were affected.

Refer to A 392.

The hospital failed to have an organized nursing service that provides 24-hour nursing services. Refer to the following:

A 392- Based on record documentation, interviews, observation, and a written statement from the wound care nurse the hospital failed to ensure that nursing care was provided to all patients and failed to ensure that proper protocols and preventive procedures be in place so that bedridden patients would not develop skin break down while they were in the hospital.

Based on record documentation, interviews, observation, and a written statement from the wound care nurse the hospital failed to ensure that nursing care was provided to all patients and failed to ensure that proper protocols and preventive procedures be in place so that bedridden patients would not develop skin break down while they were in the hospital. Three (3) out of five (5) patients reviewed did have a skin break down while they were a patient in the hospital. Patient number #1, 2, 5 were affected.

Findings:

A recent investigation for patient # one (1) revealed that the hospital did not implement hospital protocols to avoid fluid filled blister on left heel from occurring while she was a patient in the hospital.

Review of Policy GUIDELINES FOR SKIN CARE revealed that a licensed caregiver will initiate the appropriate skin care measures based on the stage and assessment of the wound. This assessment will be completed on admission to the ED and again if patient is admitted. The Braden Skin Scale will be completed by the licensed caregiver on admission and repeated daily while the patient is in the hospital. Documentation of wounds will be maintained.

Review of patient # one (1) clinical revealed that the physician ordered for the nursing staff to implement decubitus precautions. Review of patient # one (1) clinical record revealed that the patient did not have any type of decubitus precautions.

Review of patient # one (1) record revealed that she was admitted to the hospital on 2/21/10 at 7:02 p.m. for cellulites of the left arm. The ED staff nurse did not perform a skin assessment prior to admitting the patient to the medical unit. The patient was discharged from the hospital on 3/1/10 and the facility failed to perform a skin assessment at that time.

On 3/25/10 at 11:00 a.m. an interview with the charge nurse of the emergency department (ED) was performed. He revealed that he could not find a documented assessment on patient #one (1). The charge nurse revealed that all patients coming through the ED are suppose to have a full body assessment before leaving. He stated, " I do not know why the nurse failed to perform a skin assessment. "

Review of Admission Assessment to the medical unit on 2/21/10 patient # one (1) did not have a wound assessment. Patient # one (1) did have a documented wound assessment on 2/22/2010 and 2/23/2010.

On 3/25/10 at 2:30 p.m. an interview with the charge nurse revealed that she does not make work assignment for the Certified Nurse Assistant (CNA). Surveyor asks CNA how did she know when a patient needs turning? She stated we try and get them on a schedule during our shift.

On 3/25/10 at 3:00 p.m. an interview the CNA was performed. The CNA revealed that she has been working at the hospital for four (4) weeks. She revealed that she does not keep any type of documentation concerning turning the patient. She stated, " If I see that the RN has put a sheet in the patient ' s room concerning a turning schedule for the patient then I will document otherwise I do not " . The CNA reveals that she never receives an aide assessment from the registered nurse on what to do for the patient. "

Review of job description on CNA section 6:1 revealed the following: " CNA attends shift report to obtain pertinent care information from licensed nursing staff following report and throughout the shift. "

An assessment and plan on the history and physical form on 2/21/10 from the ED physician revealed that patient # one (1) have decubitus precautions in place during her stay in the hospital. No precautions were noted in clinical record.

The above findings of patient # one (1) were discussed with the DON. No additional documentation was offered.

Review of wound care nurse (WCN) job description revealed that the purpose of her job is to assess wounds referred by physicians both inpatient and outpatient. The WCN choose appropriate treatment and obtain orders for wound care until wounds are healed. Some of the essential job functions found in the job description for the WCN are as follows: Document accurate assessment and administration of all treatments including the patient ' s response. Identifies and recommends needed resources to meet the patients ' post-hospital needs. Documents teachings and instructions on flow sheet for patients care at home. The WCN maintains an active role in the hospital discharge planning program to ensure the continuity of care and documents information completely in the health record ...Review of hospital documentation policy and procedure on Guidelines For Skin Care revealed the following: (1) The licensed caregiver will complete a skin assessment of the patient on in-house admission and emergency department (ED) admissions. Documentation of findings will be done daily. (2) The Braden Skin Assessment will be completed by the licensed caregiver on admission and repeated daily. The guideline number twelve (12), revealed that all stage III and stage IV ulcers or other wounds requiring special attention will be treated by the wound care nurse.

Review of clinical record # two (2) admission orders revealed that patient # two (2) was admitted to the hospital on 3/10/10 with a diagnosis of urinary tract infection, congestive heart failure, and hypoglycemia. Admission assessment on 3/10/10 revealed
that the registered nurse failed to complete a wound assessment or Braden Skin Risk Assessment. On 3/11/10, 3/20/10, and 3/24/10 a wound care evaluation and Braden Scale was not performed as stated in hospitals ' policy.

On 3/11/10 an order for wound evaluation was ordered for patient # 2. The physician ordered to change dressings to wounds daily.

On 3/12/10 an order from wound care nurse revealed the following: " Wound care orders for floor nurse. (1) clean wounds with NS-Coccyx, left IS, Right IS, left shoulder, and right ankle lateral. (2) Cover with Aquacel AG and 4x4s-Secure with tape. (3) Change every 3 days and prn. "

On review of documentation concerning wounds for patient # two (2) the following was found. 3/12/10 " clean wounds with NS coccyx, left IS right IS, left shoulder and right ankle lateral then cover with Aquacel AG and 4x4 ' s secure with tape- change q 3 days and prn. " Medication Administration Record revealed the procedure was done on 3/12/10, and 3/15/10. No additional documentation was offered when surveyor questioned DON about days missed.

On review of hospital policy and procedure "Photographing Wounds For Documentation " revealed that photographs should be taken weekly, at discharge, and when there is a significant change to help document improvements or exacerbation. Patient # two (2) had photographs taken on 3/10/10 at time of admission only. No additional documentation offered when DON questioned about days missed.

On 3/24/10 at 3:00 p.m. a telephone interview was conducted with the hospitals wound care nurse. (WCN) She revealed that she saw patient # 2 one time on 3/12/10. She also revealed that she left orders for nurses on the unit to perform wound care. Surveyor asks if she does follow ups on patients that have stage 3 and 4 decubitus ulcers. The WCN revealed that she tries but she was so busy last week she did not have time to see patient # two (2).

On 3/26/10 at 9:00 a.m. an interview with the WCN was performed. The WCN revealed that she works under the direction of the Physical Therapy Department. She revealed that she does evaluations on inpatients, however, her main focus of he job is outpatient wound care. The WCN revealed when she was hired to the WCN position one and a half years ago she was told she would be getting another nurse to help her but, that has not happened. The WCN revealed she was not aware that the policy for inpatients with stage 3 and stage 4 decubitus ulcers or other wounds requiring special attention were to be treated by her.

On 3/26/10 the WCN performed another wound assessment at request of this surveyor. She revealed that patient # 2 had developed a new stage II ulcer on the left elbow.

On 3/26/10 the WCN gave a written summation of her role as a WCN for the hospital to surveyor. The following was revealed. " My name is _____RN, and I have about 3 years working experience with wound care. I worked in_______for 10 month where I had the job training with wounds and attended Hyperbaric Medicine team training in _____. I have been in this position at ________ for approximately 1? years. My job responsibility is doing outpatient wound care and work as a consultant for inpatient wound care. On inpatients, I am consulted. With the MD approval, I write orders for the floor nurse to follow. I do go around and check on patients, but I have not always charted on everyone that I have seen. I charted on the ones that needed to be corrected or the nurse did not do."

Review of clinical record for patient # five (5) revealed that the patient was a 94 year old female admitted to the hospital on 3/24/2010 with a diagnoses of dehydration and stage III-IV decubitus right ankle and stage I top of right foot. On 3/25/10 there was an order to change the dressing on wounds twice a day. Review of the record indicated that the dressings had not been changed on 3/25/10, or 3/26/10. When surveyor question order the LPN on duty said it was an over site and had not been done as ordered.

On 3/26/10 at 3:15 p.m. surveyor went with WCN and DON to room 349 to observe patient # five (5) wounds. Patient was found on a regular mattress bed. The LPN stated she did not know when the patient had been turned last. This surveyor ,WCN, and DON found a new stage 1 decubitus ulcer on patient ' s right lateral foot and little toe. A new stage 1 decubitus ulcer was found on left great toe. WCN confirmed stage of new wounds with surveyor.

On 3/26/10 at 4:00 p.m. the above findings were discussed with the DON. No additional documentation was offered.