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Based on interview and record review, the facility (Transferring Facility, TF) failed to completely assess Patient (Pt) 1's pressure ulcers accurately or consistently. When Pt 1 was transferred to the long term care facility (LTC), the TF failed to inform the LTC of the complete and accurate physical assessment.

On February 2, 2006, a complaint was received by the Department that a new admission to the LTC had multiple wounds and pressure sores on the coccyx and buttocks that the LTC had not been informed of before the transfer process. In addition, Pt 1's family had been unaware of the extensive pressure ulcers, which were assessed at the time of admission to the LTC.

The medical record for Pt 1 was reviewed on May 12, 2010 at 12 PM, with the Risk Manager (RM) from the TF. Pt 1 was admitted to the TF on January 9, 2006, with the diagnosis of an infection right above the knee amputation stump. There was no documentation of any pressure ulcers present on admission. The first notation of any pressure ulcer was on January 20, 2006 in the nurses' notes. The Wound Care Nurse consulted on January 21, 2006. The Wound Care Nurse identified four Stage II pressure ulcers. (Stage II ulcers are defined as a partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed.) One was on the left buttock and measured 1 x 1 cm. Three were identified on the right buttock and measured .5 x 5 cm, 1.5 x 2 cm, and 1 x 6.5 cm. Another Wound Care Nurse documented on January 23, 2006, a Stage II 8 x 2 cm pressure ulcer on the buttock, but did not specify left or right. No other documentation by the Wound Care Nurse was found in the chart for the rest of the hospitalization. The daily nurses' notes (both narrative and the check-mark Patient Physical Assess/Reassess) were reviewed from January 9-February 2, 2006. The documentation by two shifts of nurses each day do not specify or identify pressure ulcer care or presence consistently. The Interfacility Transfer Report from the TF to the LTC was reviewed. It documented: "wound to right buttocks".

On May 16, 2010, the medical record for Pt 1 was reviewed at the LTC facility. It documented that Pt 1 was admitted to the facility on February 2, 2006. The initial assessment done at that time documented 6 pressure ulcers: three on the right buttock, 1 of these Stage II and 2 Stage III. (Stage III is defined as full thickness ulcers.) The Stage II pressure ulcer was measured as 1 x 1.6 cm. The Stage III pressure ulcers were measured 15 x 9 cm and 4 x 6 cms. Two Stage II pressure ulcers were identified on the coccyx. One was 2 x 1 cm and the other 12 x 15 cm. One Stage II pressure ulcer was identified on the left heel, measuring 2 x 4 cms.