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Based on review of the medical record, policies and procedures, and staff interviews, it was determined that the facility failed to supervise care, provide consistent skin and wound care/treatment, and provide shaving/oral care to 1 of 3 (#3) sampled patient records.

Findings were:

Review of facility policy entitled "Skin/Wound Admission Assessment", last revised September 2007, revealed that the purpose of the initial skin risk assessment was to identify patients at risk of developing (or with existing) skin breaks, ulcers, or wounds in an effort to improve outcome. The policy indicated that patients that scored 18 points or lower on the Braden Risk Assessment were considered to be at risk for development of pressure ulcers and the following actions should be taken: the Multidisciplinary Skin Care Committee Skin/Wound Order Sheet was to be placed on the record to implement the appropriate recommended interventions and a head to toe assessment was to be done daily and documented. Additional documentation in facility policies revealed that the Skin/Wound Nurse would receive a daily report on any patient admitted with an assessment score of 18 or less or with a documented wound on admission. The Wound Care Nurse would make an initial assessment when the referral was received, make recommendations, and follow up one (1) time a week unless treatment indicated more frequent visits or as requested by the physician.

The initial Skin Risk Assessment of patient #3 indicated a score of 17. The risk assessment form revealed that a score of 18 or below would trigger a print out of skin/wound orders to be implemented and a referral to the Skin/Wound Nurse. The record lacked evidence that the orders were implemented or that the Skin/Wound Nurse referral was made. Skin risk assessments were completed and documented every day with the patient's risk score remaining at 17. The record indicated that the first assessment by the Skin/Wound Nurse was not done until hospital day #14.

The Skin Wound Nurse documentation, done on hospital day #14, revealed the patient had a right heel blister, a left heel blister, and a left heel deep tissue injury (DTI - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). The nurse documentation also noted blisters to the left mid distal back with the largest area measuring 3.2 cm length x 1 cm width with several blisters surrounding this area. The nurse recommended that heel blisters be covered with ABD pad (sterile dressing), wrapped with Kerlix (gauze bandage roll) for protection, and changed two (2) times a week and as needed for assessment. The nurse also recommended that the back blisters be covered with allevyn gentle dressing (special wound dressing) to be changed weekly and as needed. The physician's order sheet revealed that the physician signed for the above recommendations and treatment was initated. The nursing notes indicated that the patient was discharged five (5) days later but lacked evidence that the ankle dressings had been changed as ordered or that the wounds were reassessed prior to discharge. The nursing notes also indicated that the patient had arm bandages for seven (7) days prior to discharge with no documentation of a reason for the bandages.

An interview was conducted at 3:30 p.m. on 04/09/12 in the administrative conference room with the Director of Quality and the Accreditation Survey Coordinator. They confirmed that patient #3 had no evidence of skin lesions on admission.

During an interview at 12:00 p.m. on 04/10/12, in addition to several interviews earlier the same day, the Director of Quality, Accreditation Survey Coordinator, and Assistant Vice President of Nursing were asked to review the patient's record. After reviewing the medical record, these staff confirmed the following information: (1) the patient was not referred for a wound care assessment with the wound care nurse per facility policy after the initial admission skin assessment of 02/09/12 revealed the patient to be at risk of skin complications with a score of 17, (2) the medical record indicated that the first assessment by the wound care nurse was not done until 02/22/12 (fourteen days after admission), and (3) the dressings to the patient's ankles were to be changed twice a week but had not been changed for five (5) days at the time of discharge.

Review of facility policy entitled "General Care of All Patients", last reviewed 2011, indicated that patients would bathe, be bathed, or assisted with their bath as necessary. Clean linen and clothing would be provided at that time. In addition, incontinent patients would have partial baths and clean linens each time the bed or clothing were soiled. The policy indicated that patients would be assisted with oral hygiene to keep the mouth, teeth, or dentures clean. In addition, men would be shaved, assisted with shaving, or be shaved as necessary to keep them clean and well-groomed.

Review of the medical record revealed that the End of Shift forms lacked documented evidence to confirm that patient #3 had received or been assisted with oral care or shaving needs on nineteen (19) out of nineteen (19) days.