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Based on a review of the policies and procedures, Patient #1's medical record, and interview, it was determined the facility failed to require a registered nurse (RN):

1) had completed an admission assessment on Patient #1, to include documentation of skin breakdown and surgical wound sites;

2) and the Wound Care Nurse (WCN) had completed wound care treatments on Patient #1;

3) had completed an assessment of Patient #1's labial-gluteal and sacral-coccyx wound sites;

4) had recorded an assessment and care of Patient #1's Jackson Pratt (JP) drain; and

5) had recorded an assessment and care of Patient #1's Colostomy and Ileostomy wounds.

Findings include:

1 ) The policy, Skin Assessment and Documentation requires: "...Registered nurses will complete a head to toe assessment on admission and...document findings on the Admission Data Base (admission assessment) and complete an admit nurses note to include the description of the skin condition...."

The patient was admitted on 06/25/09, with gastrointestinal (GI) bleed and dialysis.

On 06/25/09, the RN did not document on the Admission Data Base form 1) the skin breakdown on the labial-gluteal and sacral-coccyx areas; 2) the ileostomy; or 3) the a JP drain. The RN documented under the "elimination" section of the form, "colostomy."

On 02/02/10, the Associate Administrator confirmed the following:

The nursing admission assessment, dated 06/25/09, did not have documentation of an assessment of the patient's skin breakdown located on the labial-gluteal and the sacral-coccyx area, the location, or the description of the colostomy, ileostomy or JP drain wound sites.

On 11/02/09, Patient #1 was readmitted for Intravenous (IV) line sepsis, shock and respiratory failure. On 11/03/09, at 1430, the physician ordered wound care treatments to the right and left abdominal wounds, ileostomy, fistula, and colostomy.

On 11/02/09, a RN had completed the patient's Admission Data Base form and had documented a skin breakdown on the coccyx area, had a scar located on the upper sternum, and had hand written "ostomy" under the elimination section of the form.

On 02/02/10, the Associate Administrator confirmed the following:

The RN had not documented the ostomy location or which ostomy the RN was referring to.

The RN did not document as part of the admission assessment, an assessment and location of the right and left abdominal wounds, the JP drain, or the fistula wound.

2) The hospital's policy, "Wound Care Program- December 2008" requires: "...The Wound Care Program will provide a comprehensive wound management to patients with alteration of skin integrity due to acute and chronic wounds...fistulas, and ostomy...A multidisciplinary team of wound care professionals...includes...Wound Care Nurse(WCN) ...staff nurses... (the) WCN...evaluate...skin integrity...identify wound type and identify appropriate treatment modalities...consultation will be performed within 72 hours...of admission, or 24 hours of receipt of a wound consult request...Document patient and wound assessments in the medical record...."

The hospital policy, "Skin Assessment and Documentation" requires: "...The patient's assigned nurse will be responsible for treatments ordered...."

On 02/02/10, the WCN and the Associate Administrator stated the wound care treatments are done by both the WCN and the RNs. The WCN nurse stated she documents the wound's assessments on the Wound Documentation Form (WDF) and in the nurse's progress notes.

The WCN stated the nursing staff documents wound care treatments on the Wound Treatment Record (TAR), and the skin assessments on the 24 Hour Patient Record.

The WCN stated she does a skin assessment evaluation on every patient within 24-72 hours of admission.

Patient #1's physician orders on 06/25/09, at 0845, revealed: "...left labial-gluteal fold, cleanse with wound cleanser, pat dry, apply skin prep to surrounding skin allow to dry. Cover with Allevyn...change every 5 days and as needed (PRN) for soilage and dislodgement...."

On 06/26/09, 07/13/09, and 07/22/09, the WCN documented on the WDF, as to providing wound care treatment to the labial-gluteal wound site.

On 07/10/09 and 07/15/09, the nursing staff documented on the TAR, providing wound care treatment to the labial-gluteal wound site.

The patient refused to have a labial-gluteal wound treatment on 07/20/09.

On 02/02/10, the Associate Administrator confirmed the WCN did not document on the WDF, or the nursing progress notes, as to completing Patient #1's labial-gluteal wound treatment on 07/01/09 and 07/06/09, every 5 days as ordered by the physician.

She confirmed the nursing staff did not document on the TAR, or the 24 Hour Patient Record, as to completing Patient #1's labial-gluteal wound treatment on 07/01/09 and 07/06/09, every 5 days as ordered by the physician.

The physician's orders on 06/25/09, at 0845, revealed: "...Sacral-coccygeal: cleanse with pericleanser, pat dry, apply EPC (extra protective cream) 2 times a day (BID) and PRN...."

On 02/02/10, the Associate Administrator stated when BID wound treatments are ordered, each nursing 12 hour shift will do one of the wound treatments.

On 02/02/10, the Associate Administrator confirmed the following for the 06/25/09 and 11/02/09 admissions:

The nursing staff documented the sacral-coccyx BID wound treatments for the day shift on 07/01/09, 07/02/09, 07/05/09 through 07/09/09, 07/12/09 through 07/15/09, 07/16/09 through 07/19/09, 07/21/09, and 07/23/09; and for the night shift 07/01/09 through 07/05/09, 07/09/09 through 07/14/09, and 07/22/09.

The nursing staff did not document providing 20 out of 56 BID sacral-coccyx wound care treatments to Patient #1.

The WCN did not document on either the WDF or the nurse's progress notes as to an evaluation or completing wound care treatment to the sacral-coccyx area.

During the 11/02/09 admission, Patient #1's physician's telephone orders, written by a RN, on 11/03/09, at 1430, included wound care to the right flank lateral abdomen wound (JP drain), fistula, left lateral abdomen wound (JP drain), and "...Change...pouch every 4 days...."

The WCN documented ileostomy wound and changing the appliance/pouches on 11/03/09, 11/06/09, 11/11/09, 11/12/09, 11/17/09, and 11/30/09. The WCN documented the patient refused to have wound care or have the appliance/pouches changed on 11/24/09, 11/25/09, and 11/27/09.

The WCN and the nursing staff did not document that Patient #1 had received ileostomy care or had the ileostomy pouch changed on 11/15/09, 11/20/09, and 11/23/09, as ordered by the physician, every 4 days.

During that same admission, Patient #1's physician's telephone orders, written by a RN, on 11/03/09, at 1430, revealed: "...Coccyx area (skin breakdown) - cleanse area with personal cleanser and pat dry. Apply EPC to area, BID and PRN stooling/bathing...."

The WCN and the nursing staff documented coccyx wound treatments:

On the day shift, on 11/03/09, 11/09/09, 11/15/09, 11/17/09, 11/18/09, from 11/20/09 through 11/22/09, 11/28/09, and 11/30/09; and
On the night shift from 11/15/09 through 11/18/09, 11/20/09, 11/21/09, and 11/26/09.

The patient refused wound care on 11/24/09, 11/25/09, and 11/27/09.

The day shift nursing staff did not document on the Patient #1's TAR a total of 15 out of 28 sacral-coccyx wound care treatments; and the night shift nursing staff did not document a total of 20 out of 27 sacral-coccyx wound care treatments.

3) The policy, Skin Assessment and Documentation requires: "...RN will complete a skin assessment daily...will document assessments on the Nurses 24 hour (Patient Record)...If a...non-pressure skin condition is identified...(example)...surgical wound...document on the Wound Documentation Form...The patient's assigned nurse will be responsible for treatments ordered...."

On 02/02/10, the WCN and the Associate Administrator confirmed the nursing staff are required to document an assessment of the wound site when performing wound care treatments.

The Associate Administrator confirmed the following for the 06/25/09 and 11/02/09 admissions:

The nursing staff did not document an assessment of Patient #1's labial-gluteal wound site on 07/10/09 and 07/15/09, when they performed the wound treatment.

The nursing staff documented on the TAR, as to providing sacral-coccyx wound treatments:

On the day shift: 07/01/09, 07/02/09, 07/05/09 through 07/09/09, 07/12/09 through 07/15/09, 07/16/09 through 07/19/09, 07/21/09, and 07/23/09; and
On the night shift: 07/01/09 through 07/05/09, 07/09/09 through 07/14/09, and 07/22/09.

The nursing staff did not document an assessment of Patient #1's sacral-coccyx wound site during 16 out of 23 day shift wound treatments; and 12 out of 22 night shift wound treatments.

On 11/03/09, at 1430, the physician's telephone orders, written by a RN, revealed: "...Coccyx area (skin breakdown) - cleanse area with personal cleanser and pat dry. Apply EPC to area, BID and PRN stooling/bathing...."

The nursing staff did not document Patient #1's sacral-coccyx wound site during 13 out of 28 coccyx wound care treatments; and 8 out of 27 night shift wound treatments, for a total of 25 out of 55 scheduled BID wound treatments.

4) The nursing procedure policy, Closed -Wound Drain Management requires: "...Jackson Pratt closed drainage systems...consists of perforated tubing connected to a portable vacuum unit...the tubing exit site is treated as a...surgical wound...Record the...appearance of the drain site...Record...drainage color, consistency, type, and amount...."

On 06/25/09, the RN documented on the 24 Hour Patient Record form that the patient had a "JP drain."

On 02/02/10, the Associate Administrator confirmed the following:

The nursing staff did not document on the 24 Hour Patient Record form a skin assessment of the JP drain site, from 06/25/09 through 07/01/09, and from 07/03/09 through 07/23/09, for a total of 27 out of 28 days.

The nursing staff did not document on the 24 Hour Patient Record the appearance of the drainage from the JP drain, from 06/26/09 through 06/30/09, and from 07/03/09 through 07/23/09, for a total of 26 out of 28 days.

The nursing staff did not document on the 24 Hour Patient Record the amount of drainage from the JP drain from 06/26/09 through 06/28/09, 07/04/09 through 07/07/09, 07/10/09, 07/11/09, 07/17/09, and 07/22/09, for a total of 11 out of 28 days.

5) The nursing procedure policy, Colostomy and Ileostomy Appliance Care requires: "...Record the drainage, include color, amount, type, and consistency...describe the appearance of the stoma and the peristomal skin...."

The nursing notes dated 06/25/09, at 2000, revealed: "...two (2) ostomy bags to abdomen...."

On 02/02/10, the Associate Administrator confirmed the following:

The nursing staff did not document a skin assessment for the colostomy and ileostomy sites on 06/25/09 to 07/01/09, 07/03/09, 07/05/09, 07/07/09, 07/09/09 to 07/12/09, 07/15/09, and 07/17/09 to 07/23/09, for a total of 21 out of 28 days.

The nursing staff did not document the appearance of the drainage from the colostomy and ileostomy sites on 06/26/09 to 07/03/09, 07/05/09 to 07/07/09, 07/09/09 to 07/12/09, 07/15/09, and 07/17/09 through 07/23/09, for a total of 23 out of 28 days.

The nursing staff did not document the amount of the drainage from the colostomy and ileostomy sites on 06/24/09, 06/28/09, 06/29/09, 07/05/09, 07/06/09, 07/10/09, 07/11/09, 07/17/09 through 07/20/09, and 07/22/09, for a total of 12 out of 28 days

The patient was admitted on 12/14/09, with Ventricular fibrillation and End-stage renal disease.

Patient #1's nursing admission assessment on 12/14/09, revealed, 5 wounds: upper right chest a permacath; right sided colostomy; mid-abdominal enterocutaneous fistula (ileostomy); Left arm has PICC line; left side pigtail drain (JP drain).

On 12/15/09, the RN documented on the Nurse's Progress Notes: "...at 0000...Colostomy stoma: dressing and bag changed; Stoma pink and moist; tolerated procedure...Ileostomy bag changed. Drain to left lower quadrant intact and no drainage noted...." The RN documented 50 ml (milliliters) from the ileostomy, and no amount from the colostomy.

On 02/03/09, the Associate Administrator confirmed the following :

On 12/15/09, the RN did not document the appearance and /or the amount of the drainage from the colostomy bag, and the appearance of the drainage from the ileostomy bag.

On 12/16/09, the RN documented on the Nurse's Progress Notes, "...at 0400..colostomy bag; fistula drainage (ileostomy) bag intact...."

On 12/16/09, the RN did not document if the colostomy or ileostomy bags had drainage, and if so, the appearance and amount of drainage.

On 12/17/09, the RN documented on the Nurse's Progress Notes, "...at 2100..Dressing to abdominal drain cleaned, with a dry dressing applied. Small amount of green drainage noted...."

On 12/17/09, the RN did not document the location, appearance or amount of drainage from the abdominal drain.

On 12/18/09 and 12/19/09, the nursing staff did not document an assessment of the colostomy, ileostomy, or the pigtail drain site, including any drainage amount, the appearance of any drainage, and if the pouch/bags were changed.

Based on a review of the policies and procedures, Patient #1's medical record, and interview, it was determined the facility had not required the RN staff to:

1) identify problems on Patient #1's Plan of Care at the time of admission(s);

2) review and update Patient #1's Plan of Care every shift;

3) review and update Patient #1's Plan of Care at the time of discharge; and

4) document a date when a problem is identified on Patient #1's Plan of Care.

Findings include:

1) The policy, Plan of Care requires: "...each patient receives individualized care based on his/her needs...On admission, the...RN...will review the admission and assessment data and identify the patient's needs for care....The RN will initiate an individualized plan of care...."

On 02/03/10, the Associate Administrator confirmed the following:

On 06/25/09, Patient #1 was admitted with GI bleed and dialysis. The patient was admitted with 2 areas of skin breakdown, the labial-gluteal fold and the sacral-coccyx, a colostomy, ileostomy and a JP drain.

On 06/25/09, at 0845, the physician wrote wound care orders for the labial-gluteal fold and the sacral-coccyx sites.

The RN identified on Patient #1's Plan of Care, "Alteration of Skin Integrity," acknowledging this patient's need on 07/21/09, twenty-six (26) days after the patient was admitted, and the physician had ordered wound treatments.

On 11/02/09, the patient was admitted with IV line sepsis, shock, and respiratory failure. The patient had colostomy, ileostomy, fistula, and 2 JP drains, at the time of admission.

The physician admission orders included the antibiotics Daptomycin and Primaxin.

On 11/02/09, the RN did not identify on the Plan of Care the Potential for/or Actual Infection, even though the patient was admitted with IV line sepsis and was receiving IV antibiotics.

The patient was admitted on 12/14/09, with Ventricular fibrillation and End-stage renal disease. The nursing admission assessment on 12/14/09, revealed, 5 wounds: upper right chest a permacath; right sided colostomy; mid-abdominal enterocutaneous fistula (ileostomy); left arm has PICC line; left side pigtail drain (JP drain).

On 12/14/09, the RN did not include on Patient #1's Plan of Care, an Alteration of Skin Integrity, even though 5 wounds were identified on the nursing assessment.

2) The policy, Plan of Care requires: "...The plan of care will be reviewed and updated by nursing every shift, (and) at discharge...."

On 02/02/09, the Associate Administrator confirmed the following:

The nursing staff did not document during Patient #1's admission from 06/25/09 to 07/23/09, as to reviewing the patient's Plan of Care for a total of 23 out of 56 shifts.

The nursing staff did not document during Patient #1's admission from 11/02/09 to 11/30/09, as to reviewing the patient's Plan of Care for a total of 36 out of 58 shifts.

The nursing staff did not document during Patient #1's admission from 12/14/09 to 12/19/09, as to reviewing the patient's Plan of Care for a total of 3 out of 10 shifts.

3) The policy, Plan of Care requires: "...The plan of care will be reviewed and updated...at discharge...."

On 02/02/09, the Associate Administrator confirmed the following:

The nursing staff did not update Patient #1's Plan of Care at the time of discharge on 07/23/09, 11/30/09, and 12/19/09.

4)The patient was admitted on 11/02/09, with IV line sepsis, shock, and respiratory failure. The patient had colostomy, ileostomy, fistula, and 2 JP drains.

On 02/02/09, the Associate Administrator confirmed the following:

On 11/02/09, a RN had initiated a Plan of Care and identified Alteration in Skin Integrity, but did not document the date this problem was identified.