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Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure nursing services were provided for one (1) of ten (10) sampled patients, (Patient #1).

Patient #1 entered the facility with no skin breakdown; however, the facility's failure to follow their policies and protocol related to skin breakdown prevention, the facility's failure to ensure skilled nursing services were provided in accordance with the plan of care and nursing staffs' failure to follow through with Physician's orders resulted in Patient #1 developing a Stage IV pressure ulcer. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate jeopardy was determined to exist related to Nursing Services.

Refer to A-395

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure that skilled nursing services were provided per the facility's policies and protocols and in accordance with the plan of care and failed to ensure nursing staff followed through with Physician's orders for two (2) wound care consults for one (1) of ten (10) sampled patients, (Patient #1).

Patient #1 entered the facility with no skin breakdown; however, the facility's failure to follow their policies and protocol related to skin breakdown prevention, the facility's failure to ensure skilled nursing services were provided in accordance with the plan of care and nursing staffs' failure to follow through with Physician's orders resulted in Patient #1 developing a Stage IV pressure ulcer. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate jeopardy was determined to exist related to Nursing Services.

The findings include:

Review of the facility's policy, Assessment and Reassessment of Patient-Nursing #700.04.02, dated 06/2009, identified reassessments evaluate the patient's on-going care, safety needs, response to interventions and progression towards clinical outcomes. Reassessments occur at regular intervals and with any significant change in patient's condition or diagnosis. Scopes of assessments include pressure sore and wound evaluations.

Review of the facility's policy, Doctors-Notification #700.35.08, dated 07/2009, identified that when a consult is not completed within twenty-four (24) hours, the physician requesting the consult is to be notified. Further review of the policy, revealed documentation regarding contacts should be documented as to the time, the date and to whom the message was given.

Review of the facility's policy, Pressure Ulcer/Wound Care: Assessment, Treatment and Documentation, dated 06/2009, revealed that staff are to notify the Wound Care Nurse if a patient has a score of twelve (12) or below on the Braden Scale. Further review of the policy, revealed a licensed nurse will implement the pressure ulcer/wound care protocols for appropriate pressure ulcer stage or wound. Assessment and ongoing care is documented on the Pressure Ulcer and Wound Care Flowsheet. After the Wound Care Nurse consult, determination of need for follow up is made. Follow up can occur within one week (five [5] business days), unless otherwise indicated in the progress notes.

Review of the facility's Wound Care Protocol, dated 07/2011, identified protocols for prevention; superficial yeast rash; skin tears; dry stable eschar especially on heels and toes; intact non-blanchable red/purple discoloration over bony prominences-deep tissue injury; and open wounds/ulcers with or without slough. Further review of the protocol, confirmed the prevention protocol was implemented when a patient scored a twelve (12) or less on the Braden Scale.

Review of the clinical record revealed the facility admitted Patient #1, on 01/20/12, with diagnoses which included Congestive Heart Failure and Pneumonia. Continued review revealed Patient #1 had a history of Hemiplegia, Respiratory Failure, Uncomplicated Diabetes Mellitus, Gastrostomy Status, Bilateral Above the Knee Amputation, Senile Dementia, Peripheral Vascular Disease, Transient Cerebral Ischemia, and Depressive Disorder.

Review of the admission skin assessment, dated 01/20/12 at 3:19 AM, revealed Patient #1's skin color was within defined limits (WDL) with skin integrity as otherwise dryness and redness noted to the facial area. Further review of the skin assessment revealed a purple spot on left back. There was no documented evidence as to the specific location of the purple spot or the size. Continued review revealed no documented evidence the skin assessment identified skin breakdown.

Review of the Care Plan for impaired skin integrity, dated 01/20/12, revealed Patient #1 was to be turned every two (2) hours and document the turning.

Review of the Braden Scale Assessment, completed on 01/20/12, revealed the facility assessed Patient #1 as an eleven (11). Continued review revealed patients with a score of twelve (12) or less were determined to be at high risk for skin breakdown and prevention protocol should be implemented.

Review of the turning and repositioning documentation, dated 01/20/12 and 01/21/12, validated Patient #1 remained on his/her back from 10:00 PM on 01/20/12 through 5:20 AM on 01/21/12. Further review of documentation revealed on 01/22/12 Patient #1 remained on his/her back from 5:00 PM to 10:10 PM. Continued review of the clinical record revealed on 01/23/12, Patient #1 laid on his/her left side from 1:00 AM until 5:58 AM. On 01/23/12, documentation indicated Patient #1 was on his/her back from 2:47 PM until 7:48 PM. Then, from 7:48 PM until 11:31 PM Patient #1 laid on his/her right side.

Interview with Registered Nurse (RN) #6, on 03/01/12, at 12:30 PM, revealed she recalled taking care of Patient #1. Review of the turning and repositioning documentation with RN #6, validated several days (01/20/12-01/23/12) Patient #1 laid in the same position, without being turned or reposition for up to seven (7) hours at a time. Continued interview revealed this was against the facility's turning and repositioning protocol because Patient #1 was at risk for skin breakdown, according to the Braden Scale Assessment. Continued interview validated staff did not adhere to the turning and repositioning guidelines planned for Patient #1. RN #6 confirmed Patient #1 was supposed to be turned and repositioned every two (2) hours.

Further review of the turning and repositioning documentation, revealed on 02/02/12, Patient #1 remained on his/her back from 6:26 AM to 11:04 AM. Continued review revealed, on 02/03/12 Patient #1 laid on the left side from 5:33 AM until 10:21 AM, and from 7:44 PM to 12:37 AM laid on his/her left side.

Interview with RN #8, on 03/01/12 at 2:10 PM, while reviewing the turning and repositioning documentation, revealed the documentation for turning and repositioning validated staff did not turn the patient as Care Planned and per the facility's protocol. Interview with State Registered Nursing Assistant (SRNA) #2, on 03/06/12, at 3:01 PM, revealed it was the responsibility of the SRNAs and the Nurses for charting the turning and repositioning of patients.

Review of the clinical record revealed the facility assessed the skin condition as red, dry and warm with excoriation to the perineal area. No other skin issues were identified.

Review of the clinical record Progress Note, dated 02/04/12, noted Patient #1 had a blistered area to the left buttock. Further review of the Progress Note, revealed no measurements of the blistered area were documented. Continued review of Progress Note, dated 02/04/12 at 7:30 PM, identified the blister to the left buttock had sloughed open.

Review of the clinical record Progress Note, dated 02/05/12, revealed a wound care consult was ordered for the open blister on the left buttock. Further review of the Progress Note, revealed the buttock was excoriated but with no drainage. The Progress Note, dated 02/06/12, indicated the coccyx wound was open and Xenaderm was applied and left open to air.

Review of the Wound Care Nurse's Note, dated 02/06/12, revealed the area was on the left-mid coccyx and was classified as a deep tissue injury that was evolving. Further review of the Note, confirmed this area was not a preexisting area. Interview with Wound Care Director/RN #3, on 03/01/12 at 1:00 PM, revealed on her assessment on 02/06/12, when she measured the area it was eight (8) centimeters (cm) by five (5) cm and it was evolving and demarcating. Review of the Care Plan revealed it was revised to include interventions to use a Maxislide for turning and pulling the patient up in bed; keep head of bed no higher that 30 degrees; use bathing products, no soap; limit padding between patient and bed; do not use donuts for coccyx; and nutrition consult.

Review of Nurse's Progress Note, dated 02/08/12, indicated a call was placed to the Physician to make him aware that Patient #1 had two (2) "very bad wounds", one (1) on the left upper back by the shoulder and one (1) on coccyx. Further review of the Progress Note, confirmed a verbal order from the Physician was obtained for a wound care consult.

Interview with RN #12, on 03/01/12, at 3:30 PM, revealed she was the RN caring for Patient #1 on 02/08/12 and that she had contacted the Physician for a wound consult when she visualized the area to the buttocks. Further interview, revealed she identified a new area to the left upper shoulder that was pink and purplish in color. Continued interview revealed after the order for the wound consult was placed into the computer system, she was not contacted by anyone from wound care.

Interview with the Wound Care Director/RN #3, on 03/01/12 at 1:00 PM, revealed she had assessed Patient #1's skin on 02/06/12, therefore did not re-assess the skin on 02/08/12, even though there was a Physician's order and Patient #1's skin condition had changed.

Review of Nurse's Progress Note, dated 02/09/12, revealed the area was described as having dark edges, dry, scant amount of serosanguinous drainage. An additional progress note, dated 02/09/12, identified the area to the coccyx as a pressure ulcer. Review of the Progress Note, dated 02/11/12, identified the coccyx as having yellowish brown drainage and a necrotic area. Further review of Progress Note, dated 02/11/12 at 10:17 PM, revealed the area was described as having red dark edges, dry and a small amount of serosanguinous (thin and red) drainage. Review of Physician's Orders, dated 02/11/12, confirmed an additional order for a Wound Care consult.

Interview with the Wound Care Director/RN #3, on 03/01/12 at 1:00 PM, revealed 02/11/12 was on a Saturday and the facility did not conduct Wound Consults on the weekends, therefore the earliest assessment, by the Wound Care Nurse (WCN), would have been completed on Monday, 02/13/12. Continued interview revealed RN #3 revealed she agreed that the Physician's ordered Wound Care consult was appropriate due to the presence of necrotic tissue. Continued interview revealed when the WCN received the orders on 02/08/12 and 02/11/12, they called back to the nurse to question the need for the consult, but there was no documented evidence for either of the additional consults.

Review of the Progress Note, dated 02/12/12 at 8:30 PM, revealed the area was described as having dark edges, red, scant amount of serosanguinous drainage. Review of the Progress Note, dated 02/13/12 at 1:00 PM, revealed the coccyx area was described as having dark edges, black and necrotic, with drainage and swelling. The peri-wound area was described as being dry and excoriated. The area was identified as non-healing.

Interview with Wound Care Director/RN #3, on 03/01/12 at 1:00 PM, revealed when reviewing the Progress Note dated 02/13/12, she agreed with the description of necrotic tissue and agreed with the Wound Care consult that was ordered on 02/11/12. Continued interview revealed, Patient #1 should have had a follow-up visit on 02/13/12, but did not.

Review of the Progress Note, dated 02/14/12 at 9:17 AM, revealed the area was described as ecchymotic (purplish spots), dry, warm and excoriated. Review of the Nurse's Progress Note/Skin Assessment, dated 02/14/12, the date of discharge, revealed the area was described as having excoriation to the coccyx and a purple spot on the left back. Further review of the assessment revealed the area was described as a deep tissue injury with defined dark edges, edema, bleeding, tunneling, dry and excoriated. The Peri-wound was dry and excoriated with a small amount of sanguinous (red) drainage with no odor.

Interview with the Vice President of Nursing Services (VPNS), on 03/02/12, at 1:15 PM, revealed the identified area to Patient #1's buttock/coccyx was facility acquired. Further interview confirmed, the facility had failed to turn and reposition Patient #1, per the Care Plan and the facility's protocol. Continued interview validated the facility did not have wound care nurses scheduled seven (7) days a week. She continued to state that when a Physician wrote an order, the nurses were to implement the Physician's order to ensure continuity of care. The VPNS further stated, notifications and protocols were not followed properly by the nursing staff. Continued interview validated, the facility did not have a process for monitoring the wound care program to ensure the facility's protocol and policies were adhered to and implemented.

Interview with RN #7/Director of Acute Care Services, on 03/02/12, at 3:45 PM, revealed she became more aware and knowledgeable of Patient #1 a couple of days before discharge when a staff nurse brought to her attention Patient #1's wound care issues. Review of the clinical record with RN #7, confirmed the facility failed to follow policy and procedures for wound care prevention and failed to implement appropriate measures according to the wound care protocols. RN #7 stated, "This is unacceptable practice. This would be considered a facility acquired wound." Continued interview confirmed, the wound care nurses should have assessed Patient #1 after the Physician's orders on 02/08/12 and again after the 02/11/12 for wound Care consult. Further interview, revealed the facility had no process in place to monitor the wound care program.

Interview with the WCN/Advance Practice Registered Nurse (APRN) #1, of the Wound Care Center, on 03/05/12, at 3:50 PM, revealed she was currently treating Patient #1 at a long term care (LTC) facility. Further interview, revealed she did not provide care to Patient #1 until after the hospitalization of 01/20/12 through 02/14/12 when he/she returned to the LTC facility with what she classified as a Stage IV decubitus ulcer on the coccyx/buttocks region. Continued interview confirmed Patient #1 was admitted to the hospital without any skin issues and was discharged with a Stage IV, measuring 13 centimeters (cm) by 11 cm with a depth of 2.8 cm. Further interview revealed the areas acquired during the hospitalization required debridement four (4) times since Patient #1 was discharge from acute care hospital.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure that skilled nursing services were provided per the facility's policies and protocols and in accordance with the plan of care and failed to ensure nursing staff followed through with Physician's orders for two (2) wound care consults for one (1) of ten (10) sampled patients, (Patient #1).

Patient #1 entered the facility with no skin breakdown; however, the facility's failure to follow their policies and protocol related to skin breakdown prevention, the facility's failure to ensure skilled nursing services were provided in accordance with the plan of care and nursing staffs' failure to follow through with Physician's orders resulted in Patient #1 developing a Stage IV pressure ulcer. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate jeopardy was determined to exist related to Nursing Services.

The findings include:

Review of the facility's policy, Assessment and Reassessment of Patient-Nursing #700.04.02, dated 06/2009, identified reassessments evaluate the patient's on-going care, safety needs, response to interventions and progression towards clinical outcomes. Reassessments occur at regular intervals and with any significant change in patient's condition or diagnosis. Scopes of assessments include pressure sore and wound evaluations.

Review of the facility's policy, Doctors-Notification #700.35.08, dated 07/2009, identified that when a consult is not completed within twenty-four (24) hours, the physician requesting the consult is to be notified. Further review of the policy, revealed documentation regarding contacts should be documented as to the time, the date and to whom the message was given.

Review of the facility's policy, Pressure Ulcer/Wound Care: Assessment, Treatment and Documentation, dated 06/2009, revealed that staff are to notify the Wound Care Nurse if a patient has a score of twelve (12) or below on the Braden Scale. Further review of the policy, revealed a licensed nurse will implement the pressure ulcer/wound care protocols for appropriate pressure ulcer stage or wound. Assessment and ongoing care is documented on the Pressure Ulcer and Wound Care Flowsheet. After the Wound Care Nurse consult, determination of need for follow up is made. Follow up can occur within one week (five [5] business days), unless otherwise indicated in the progress notes.

Review of the facility's Wound Care Protocol, dated 07/2011, identified protocols for prevention; superficial yeast rash; skin tears; dry stable eschar especially on heels and toes; intact non-blanchable red/purple discoloration over bony prominences-deep tissue injury; and open wounds/ulcers with or without slough. Further review of the protocol, confirmed the prevention protocol was implemented when a patient scored a twelve (12) or less on the Braden Scale.

Review of the clinical record revealed the facility admitted Patient #1, on 01/20/12, with diagnoses which included Congestive Heart Failure and Pneumonia. Continued review revealed Patient #1 had a history of Hemiplegia, Respiratory Failure, Uncomplicated Diabetes Mellitus, Gastrostomy Status, Bilateral Above the Knee Amputation, Senile Dementia, Peripheral Vascular Disease, Transient Cerebral Ischemia, and Depressive Disorder.

Review of the admission skin assessment, dated 01/20/12 at 3:19 AM, revealed Patient #1's skin color was within defined limits (WDL) with skin integrity as otherwise dryness and redness noted to the facial area. Further review of the skin assessment revealed a purple spot on left back. There was no documented evidence as to the specific location of the purple spot or the size. Continued review revealed no documented evidence the skin assessment identified skin breakdown.

Review of the Care Plan for impaired skin integrity, dated 01/20/12, revealed Patient #1 was to be turned every two (2) hours and document the turning.

Review of the Braden Scale Assessment, completed on 01/20/12, revealed the facility assessed Patient #1 as an eleven (11). Continued review revealed patients with a score of twelve (12) or less were determined to be at high risk for skin breakdown and prevention protocol should be implemented.

Review of the turning and repositioning documentation, dated 01/20/12 and 01/21/12, validated Patient #1 remained on his/her back from 10:00 PM on 01/20/12 through 5:20 AM on 01/21/12. Further review of documentation revealed on 01/22/12 Patient #1 remained on his/her back from 5:00 PM to 10:10 PM. Continued review of the clinical record revealed on 01/23/12, Patient #1 laid on his/her left side from 1:00 AM until 5:58 AM. On 01/23/12, documentation indicated Patient #1 was on his/her back from 2:47 PM until 7:48 PM. Then, from 7:48 PM until 11:31 PM Patient #1 laid on his/her right side.

Interview with Registered Nurse (RN) #6, on 03/01/12, at 12:30 PM, revealed she recalled taking care of Patient #1. Review of the turning and repositioning documentation with RN #6, validated several days (01/20/12-01/23/12) Patient #1 laid in the same position, without being turned or reposition for up to seven (7) hours at a time. Continued interview revealed this was against the facility's turning and repositioning protocol because Patient #1 was at risk for skin breakdown, according to the Braden Scale Assessment. Continued interview validated staff did not adhere to the turning and repositioning guidelines planned for Patient #1. RN #6 confirmed Patient #1 was supposed to be turned and repositioned every two (2) hours.

Further review of the turning and repositioning documentation, revealed on 02/02/12, Patient #1 remained on his/her back from 6:26 AM to 11:04 AM. Continued review revealed, on 02/03/12 Patient #1 laid on the left side from 5:33 AM until 10:21 AM, and from 7:44 PM to 12:37 AM laid on his/her left side.

Interview with RN #8, on 03/01/12 at 2:10 PM, while reviewing the turning and repositioning documentation, revealed the documentation for turning and repositioning validated staff did not turn the patient as Care Planned and per the facility's protocol. Interview with State Registered Nursing Assistant (SRNA) #2, on 03/06/12, at 3:01 PM, revealed it was the responsibility of the SRNAs and the Nurses for charting the turning and repositioning of patients.

Review of the clinical record revealed the facility assessed the skin condition as red, dry and warm with excoriation to the perineal area. No other skin issues were identified.

Review of the clinical record Progress Note, dated 02/04/12, noted Patient #1 had a blistered area to the left buttock. Further review of the Progress Note, revealed no measurements of the blistered area were documented. Continued review of Progress Note, dated 02/04/12 at 7:30 PM, identified the blister to the left buttock had sloughed open.

Review of the clinical record Progress Note, dated 02/05/12, revealed a wound care consult was ordered for the open blister on the left buttock. Further review of the Progress Note, revealed the buttock was excoriated but with no drainage. The Progress Note, dated 02/06/12, indicated the coccyx wound was open and Xenaderm was applied and left open to air.

Review of the Wound Care Nurse's Note, dated 02/06/12, revealed the area was on the left-mid coccyx and was classified as a deep tissue injury that was evolving. Further review of the Note, confirmed this area was not a preexisting area. Interview with Wound Care Director/RN #3, on 03/01/12 at 1:00 PM, revealed on her assessment on 02/06/12, when she measured the area it was eight (8) centimeters (cm) by five (5) cm and it was evolving and demarcating. Review of the Care Plan revealed it was revised to include interventions to use a Maxislide for turning and pulling the patient up in bed; keep head of bed no higher that 30 degrees; use bathing products, no soap; limit padding between patient and bed; do not use donuts for coccyx; and nutrition consult.

Review of Nurse's Progress Note, dated 02/08/12, indicated a call was placed to the Physician to make him