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Based on observation, interview and record review, the facility nursing staff failed to develop, and keep current, a nursing care plan for 2 out of 10 sampled patients in : 1) ensuring a sacral pressure ulcer did not get worse for one sampled patient # 1. 2) preventing further skin breakdown for sampled patients #9 by implementing preventive measures.

The findings include:

1) Clinical record review revealed that SP#1 presented to the facility April 20, 2012, via the emergency department with a chief complaint of fall at her home and slurred speech. Her diagnoses include (but are not limited to): cerebrovascular accident, atrial fibrillation, congestive heart failure, hemorrhagic stroke. The patient presented to the facility with no pressure ulcers and skin that was intact. There was a nursing skin assessment using a Braden scale, which scored SP#1 at nine (15); which according to their legend places the patient at moderate risk for skin breakdown. The patient was subsequently admitted to the facility, underwent multiple invasive procedures, and a decline in medical status. Her length of stay at the facility was 56 days, some of which included admission in the intensive care unit. She was eventually discharged from the facility to a long term acute care facility on 6/15/2012.

Review of the wound care notes, on 4/26/2012, reveal that SP#1 developed a stage I pressure ulcer to the sacral area. The following are the characteristics and outcome of this wound prior to discharge from the facility: 5/10/2012: Stage II; bilateral buttocks: Length=2 centimeters; width=2 centimeters; depth= 0.2 centimeters; no additional characteristics were documented for this date. 5/18/2012: Stage II; sacrum; no measurements and no wound characteristics were documented for this date. 6/7/2012 (20 days later): Sacrum wound: measures: length= 3.1 centimeters; width= 3.2 centimeters; depth= " ? " characteristics: serosanguinous drainage and yellow/tan slough; there was no stage data documented. 6/13/2012: Unstageable sacral wound; measurements: length= 1.6 centimeters; width=3 centimeters; depth= 1.0 centimeters.

Interview with the quality officer on 6/27/2012 at 10:44am, she confirms the above findings regarding Patient #3.



2) Observation of Patient #9 on 6/26/2012 at 12:49pm, revealed that she was in the emergency department, and had presented there with a chief complaint of allergic reaction. There was family at the bedside. Patient #9 was alert, her speech was unintelligible. The patient was lying in a stretcher and appeared distressed. There was an odor present. With the aid of the assigned nurse, Patient #9 was observed to be lying on 2 blue pads. These were visibly wet and soiled with a brown colored substance. There was a stack of 4 by 4 gauze pads in the perineal area. Upon further assessment, the patient was observed with a pink to red rash in the entire perineal area. The assigned nurse reported that this was not the skin care protocol nor was it the expected for prevention of skin breakdown. The nurse was then observed cleaning the patient ' s perineal area, applying skin barrier cream, discarding the soiled pads and replacing them with dry ones and then placed an incontinence brief on the resident. He was then observed, with additional staff assistance, changing the resident from the stretcher to a patient bed. He reported that the patient had orders to be admitted to the facility. The family at the bedside voiced concern that the facility did not place an incontinence brief on the patient hours ago. She was visibly upset.

Interview with the Chief Nursing Officer, who was present with this surveyor during the above observation, she reports that it is the facility ' s policy to use incontinence brief minimally. She confirms that the above observation occurred and is not the facility ' s skin care protocol.

Based on interview and record review, the facility failed to ensure a physician order was in place, prior to administration of pain medication for 1 (Patient #3) out of 10 sampled patients (SP).

The findings include:

Clinical record review revealed that Patient # 3 presented to the facility via the emergency department with a chief complaint of chest pain. His diagnoses include (but are not limited to): hypertension, right pleural effusion, coronary artery disease, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and bipolar disorder. He underwent thoracotomy with decortation surgery at the facility on 5/16/2012. During his stay in the recovery room, a staff nurse administered morphine 4 milligrams via intravenous route, for pain. However there was no corresponding physician order for this medication, at this dosage on Patient #3 ' s medical record.

Interview with the quality officer on 6/27/2012 at 10:44 am, she confirms the above findings regarding Patient #3.

Based on observation, interview and record review, the facility nursing staff failed to develop, and keep current, a nursing care plan for 2 out of 10 sampled patients in : 1) ensuring a sacral pressure ulcer did not get worse for one sampled patient # 1. 2) preventing further skin breakdown for sampled patients #9 by implementing preventive measures.

The findings include:

1) Clinical record review revealed that SP#1 presented to the facility April 20, 2012, via the emergency department with a chief complaint of fall at her home and slurred speech. Her diagnoses include (but are not limited to): cerebrovascular accident, atrial fibrillation, congestive heart failure, hemorrhagic stroke. The patient presented to the facility with no pressure ulcers and skin that was intact. There was a nursing skin assessment using a Braden scale, which scored SP#1 at nine (15); which according to their legend places the patient at moderate risk for skin breakdown. The patient was subsequently admitted to the facility, underwent multiple invasive procedures, and a decline in medical status. Her length of stay at the facility was 56 days, some of which included admission in the intensive care unit. She was eventually discharged from the facility to a long term acute care facility on 6/15/2012.

Review of the wound care notes, on 4/26/2012, reveal that SP#1 developed a stage I pressure ulcer to the sacral area. The following are the characteristics and outcome of this wound prior to discharge from the facility: 5/10/2012: Stage II; bilateral buttocks: Length=2 centimeters; width=2 centimeters; depth= 0.2 centimeters; no additional characteristics were documented for this date. 5/18/2012: Stage II; sacrum; no measurements and no wound characteristics were documented for this date. 6/7/2012 (20 days later): Sacrum wound: measures: length= 3.1 centimeters; width= 3.2 centimeters; depth= " ? " characteristics: serosanguinous drainage and yellow/tan slough; there was no stage data documented. 6/13/2012: Unstageable sacral wound; measurements: length= 1.6 centimeters; width=3 centimeters; depth= 1.0 centimeters.

Interview with the quality officer on 6/27/2012 at 10:44am, she confirms the above findings regarding Patient #3.



2) Observation of Patient #9 on 6/26/2012 at 12:49pm, revealed that she was in the emergency department, and had presented there with a chief complaint of allergic reaction. There was family at the bedside. Patient #9 was alert, her speech was unintelligible. The patient was lying in a stretcher and appeared distressed. There was an odor present. With the aid of the assigned nurse, Patient #9 was observed to be lying on 2 blue pads. These were visibly wet and soiled with a brown colored substance. There was a stack of 4 by 4 gauze pads in the perineal area. Upon further assessment, the patient was observed with a pink to red rash in the entire perineal area. The assigned nurse reported that this was not the skin care protocol nor was it the expected for prevention of skin breakdown. The nurse was then observed cleaning the patient ' s perineal area, applying skin barrier cream, discarding the soiled pads and replacing them with dry ones and then placed an incontinence brief on the resident. He was then observed, with additional staff assistance, changing the resident from the stretcher to a patient bed. He reported that the patient had orders to be admitted to the facility. The family at the bedside voiced concern that the facility did not place an incontinence brief on the patient hours ago. She was visibly upset.

Interview with the Chief Nursing Officer, who was present with this surveyor during the above observation, she reports that it is the facility ' s policy to use incontinence brief minimally. She confirms that the above observation occurred and is not the facility ' s skin care protocol.

Based on interview and record review, the facility failed to ensure a physician order was in place, prior to administration of pain medication for 1 (Patient #3) out of 10 sampled patients (SP).

The findings include:

Clinical record review revealed that Patient # 3 presented to the facility via the emergency department with a chief complaint of chest pain. His diagnoses include (but are not limited to): hypertension, right pleural effusion, coronary artery disease, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and bipolar disorder. He underwent thoracotomy with decortation surgery at the facility on 5/16/2012. During his stay in the recovery room, a staff nurse administered morphine 4 milligrams via intravenous route, for pain. However there was no corresponding physician order for this medication, at this dosage on Patient #3 ' s medical record.

Interview with the quality officer on 6/27/2012 at 10:44 am, she confirms the above findings regarding Patient #3.