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Based on the review of two separate records for patient #1, he suffered skin breakdown on both feet and his coccyx between 12/25/10 and 12/27/10, while hospitalized for pylonephritis. He was discharged on 12/28 at 1500 with his caregivers. On his second admission at 1710 on 12/28 in an ED assessment there were wounds present on the left heel, back of right thigh and bilateral buttocks, as well as bilateral 4+ edema to both hands and feet. It could not be determined that the patient was safely cared for during his hospitalization.

Findings were:

Based on review of the two admission for patient #1 he was admitted on 12/25/10 and his skin assessment was documented as clear. He was ambulatory with his walker and toileted independently. On 12/27 the R.N. documented stage I skin breakdown on the patients coccyx, right and left feet. On 12/25 the skin assessment was blank except for "none" written indicating clear skin. On 12/26 the skin assessment for both shifts indicated "none" for skin breakdown. On 12/27 the first shift indicated no skin breakdown, however, the second shift indicated three wounds described as "unstageable". The first was on the coccyx, with slough, granulation and epithelialization. The left and right feet were described with slough, eschar, granulation and epithelialization. On the 28th the area for wounds/incision/breakdown was marked as "none". He was discharged on 12/28 at 1500 to caregivers.

At 1710 on 12/28 this patient was brought back to the hospital via ambulance to the emergency department. He had a temperature of 102 degrees and was very weak being unable to walk or stand. On admission to the floor on 12/29 his wounds were documented. Also on the 29 and 30th his scrotum and penile area were noted as red and swollen with no further documentation. No documentation of physician notification.
He was documented as bedridden and transfer with assist times 4 throughout his stay.
The patient was incontinent of urine and stool, and required cleaning by nursing staff.
No bathing was documented on 12/31, 1/1, 1/3 1/4, 1/6 and he refused on 1/5.
Although this patient was independent in a group home, after his hospital stay, he required placement in a nursing facility for rehabilitation as he was now a total care patient. .
This was confirmed in interview on 1/13 with the quality management staff at the hospital.

The hospital failed to ensure that the nursing care for patient #1 was supervised or evaluated by a registered nurse as this patient was admitted to the hospital on 12/25/10 with clear skin; at discharge on 12/28 the caregivers saw wounds on the patient's feet and coccyx when he was brought to the group home. After the second admission, on 12/28 to 1/6/11, the patient was no longer able to walk or stand.

Findings were:

1.
Patient #1 was admitted on 12/25/10 and his skin assessment was documented as clear. He was ambulatory with his walker. On 12/25 the skin assessment was blank except for "none" written indicating clear skin. On 12/26 the skin assessment for both shifts indicated "none" for skin breakdown. On 12/27 the first shift indicated no skin breakdown, however, the second shift indicated three wounds described as "unstageable". The first was on the coccyx, with slough, granulation and epithelialization. The left and right feet were described with slough, eschar, granulation and epithelialization. On the 28th the area for wounds/incision/breakdown was marked as "none". He was discharged on 12/28 at 1500 to caregivers.

At 1710 on 12/28 this patient was brought back to the hospital via ambulance to the emergency department. On admission to the floor on 12/29 his wounds were documented. Also on the 29 and 30th his scrotum and penile area were noted as red and swollen with no further documentation and no documentation of physician notification. He was documented as bedridden and transfer with assist times 4, throughout his stay. No bathing was documented on 12/31, 1/1, 1/3 1/4, 1/6 and he refused on 1/5. Although this patient was independent at home, after this hospital stay, he required placement in a nursing facility for rehabilitation as he was now a total care patient. .
This was confirmed in interview on 1/13 with the quality management staff at the hospital.

Based on review of the clinical record from 12/28 through 1/6 for patient #1 and interview with staff, the clinical nutrition staff failed to follow a physician order for a dietary consult as the patient required the skin care protocols, to be initiated for the patient's open wounds

Findings were:

Although the skin care protocols were ordered to be followed as patient #1 had four open wounds (left foot, left thigh and bilateral buttocks) there was no documentation to indicate that the order for the Dietary consult was completed during the hospitalization. This was confirmed through interview on 1/13 with the quality management staff.

Based on review of the medical record for patient #1, there was no evidence of any discharge planning. Patient #1 was hospitalized between 12/25 and 12/28. The initial discharge planning space was blank on admission nursing assessment; there were no notes from a discharge planner or a social worker.

Findings were:

Patient #1 was hospitalized between 12/25 and 12/28. There was not a case management discharge plan of care. The initial assessment for discharge planning on the admission nursing notes was blank. There was no evaluation if the patient could continue to be cared for in the same living situation prior to hospitalization. This was confirmed in interview on 1/13/11 with the quality management staff.