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Based on record review and staff interview, the Hospital failed to identify and adequately assess three of three applicable medical records for Patient's (#1, #2 and #3) identified with Stage 2 pressure ulcers. The Hospital failed to identify areas of improvement after a complaint was filed with the Hospital for Patient #1 who lacked any measurable assessment of a pressure ulcer until the day of discharge in July 2010.

The findings are as follow:

Refer to Tag A-0395

The Clinical Specialist was interviewed on 03/03/11 at 2:18 PM. The Clinical Specialist said staff were provided with additional training following Patient #1's discharge in August 2010.

Review of the Pressure Sore Training Material attachment for the inservice done on 09/16/10 indicated the nursing staff were provided with education as to identifying Stage I pressure ulcers.

There was no documented training for the lack of Wound Assessments for Patient's #1, who developed a coccyx wound identified as a Stage 2 on or about 07/26/10. There was no documentation or assessment of Patient #1's wound until the day of transfer to a skilled nursing facility on 07/31/10.

The VP of Nursing/Chief Nursing Officer was interviewed on both days of survey. The VP of Nursing said the Wound Care Team conducted prevalence studies quarterly whereby a team evaluated all patients with the exception of obstetrical patients each quarter for the presence of pressure ulcers. The Team then documented whether the patients pressure ulcers were present on admission or health care associated/hospital acquired. The VP of Nursing said each inpatient unit had trained nursing staff to utilize as a resource for the assessment of patients with pressure ulcers. The VP of Nursing said there were two Wound Nurse Consultants available to the staff and for the assessment of patients in need of consultation.

There was no retrievable audit tool or system for tracking patients with pressure ulcers nor evidence of monitoring patient care and/or documentation for the management of patients with pressure ulcers.

Patient #1:

Patient #1 was admitted to the Hospital on 07/20/10. Patient #1 had intact skin without of any signs of skin breakdown or pressure ulcers.

Registered Nurse #4 was interviewed on 03/03/11 at 11 AM. RN #4 said on 07/30/10 Patient #1 was scheduled for a percutaneous endoscopic gastrostomy (PEG) tube insertion. RN #4 said because Patient #1 was going to the operating room, two dressings were changed on the buttock area. RN #4 said one area was reddened and the second area was open with black eschar on the edge. RN #4 said Patient #1 had a Stage III pressure ulcer. RN #4 documented Patient #1 had two Mepilex intact dressings on buttocks. RN #4 documented Patient #1 had pink, intact heels elevated on a pillow. RN #4 said a Wound Assessment was required to document Patient #1's pressure ulcer. RN #4 was scheduled to work the next day and intended to document Patient #1's pressure ulcer on 07/31/10. RN #4 said the Wound Assessment intervention was needed on 07/30/10 and RN #4 planned on documenting the Wound Assessment but did not have time. RN #4 was aware that a Wound Assessment was never documented and failed to conduct an immediate assessment for Patient #1 with a Stage III pressure ulcer. RN #4 did not notify a physician or request assistance from a clinical specialist to consult with the appearance, stage and measurement of Patient #1's coccyx/buttock wound.

Documentation on 07/30/10 at 12 AM indicated the Nursing Assessment repeated the previous entry: Mepilex times two on buttocks, reported as a Stage 2. Patient #1's heels pink, intact and elevated on a pillow.

Documentation dated 07/30/10 and 07/31/10 indicated Registered Nurse #4 was assigned to Patient #1 during the 7 AM to 7 PM shift. The Nursing Assessment dated 07/30/10 at 9 AM indicated Mepilex times two on buttocks, reported as a Stage 2 on buttocks. Patient #1 heels pink, intact and elevated on a pillow.

Review of the Hospital's Skin At Risk Algorithm indicated Stage III presents as full thickness tissue loss involving damage or necrosis that may extend down to, but not through fascia. Clinically presents as a deep crater, with or without undermining and may be shallow if located on an area without significant fat.

Review of the Nursing Assessment for Patient #1 dated 07/31/10 at 10 AM, by RN #4 indicated a Stage 2 (versus a Stage III) pressure ulcer was located on the coccyx with a small amount of drainage and eschar noted in the center of the wound. RN #4 indicated the edges to the pressure ulcer were pink. RN #4 documented the area was cleansed with normal saline and covered the area with a Mepilex dressing.

Review of the Hospital's Skin At Risk Algorithm indicated an Unstageable pressure ulcer was defined as a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. When eschar is present, accurate staging is not possible until it is removed. If dry, black, it may need surgical (sharp) debridement. If moist, tan/yellow slough, debridement may be done autolytically, by enzymatic agents or mechanically by wet to dry dressing.

The Hospital's Skin At Risk Algorithm indicated with the presence of necrosis consult Skin and Wound nurse or the units skin specialist.

Review of the Wound Assessment as documented by RN #4 on 07/31/10 at 10 AM contradicted the documentation in the Nursing Assessment. RN #4 indicated Patient #1 had a coccyx pressure ulcer which was unstageable. RN #4 indicated the wound appearance had minimal, old, brown drainage with mild odor. RN #4 indicated the wound bed was pink. RN #4 indicated a documentary photograph was not taken.

Review of the Discharge Planning Note by RN #4 dated 07/31/10 at 1 PM indicated Patient #1's coccyx pressure ulcer measured 1 centimeter by 1 centimeter of eschar with surrounding pink tissue. RN #4 said the measurement referred to the center of Patient #1's pressure ulcer.

An additional Wound Assessment was documented on 07/31/10 at 2 PM by RN #4. RN #4 indicated Patient #1's coccyx pressure ulcer was unstageable. RN #4 documented the wound appearance was clean and dry (versus the previous assessment of minimal, old brown drainage with a mild odor) and the wound bed was pink. RN #4 indicated there was no drainage and the surrounding tissue was pink. RN #4 indicated a photograph was taken.

A Discharge Planning Note written on 07/31/10 at 6 PM by RN #4 indicated the measurement of Patient #1's pressure ulcer was (incorrectly entered) as 21 centimeters by 2.8 centimeters of eschar with minimal drainage and surrounding tissue was pink.

RN #4 said another nurse on the unit trained in measuring pressure ulcers photographed Patient #1's coccyx pressure ulcer and measured Patient #1's pressure ulcer.

A Documentary Photograph of Patient #1's coccyx pressure ulcer measured 2.1 centimeters by 2.8 centimeters. There was necrotic tissue in the center and slough surrounding the darkened area. The Documentary Photograph was incorrectly dated 07/20/10.

The Wound Nurse was interviewed on 03/03/11 at 12:30 PM. The Wound Nurse said a skin care team was formed several years ago. The Wound Nurse said training had been provided to staff on the inpatient units to assist in the assessment of patients with pressure ulcers. The Wound Nurse was not involved with Patient #1's assessment. The Wound Nurse said review of the Documentary Photograph indicated there were no signs of infection. The Wound Nurse said an autolytic debridement with dressing could have been attempted. The Wound Nurse said Mepilex dressing is absorptive and does not cause trauma when removed.

Review of the Medical Progress Note dated 07/31/10 at 11:59 AM indicated Patient #1 was positive for the development of sacral wound. There was no further documentation regarding the status of Patient #1's sacral wound. There was no documented wound consultation for the assessment of Patient #1's wound.

There was no discharge referral documentation by nursing for the description of Patient #1's pressure ulcer..

There was no evidence Patient #1 was evaluated by a qualified wound nurse and/or physician to determine the appropriate course of treatment and plan for Patient #1's wound care.

The Nurse Manager was interviewed in person on 03/01/11 at 1:20 PM The Nurse Manager denied having any knowledge of patients with pressure ulcers on the inpatient unit.

A tour of the inpatient unit on 03/01/11 indicated Patient #2 had a Stage 2 pressure ulcer and was discharged.

Patient #2

Patient #2 was admitted to the Hospital on 02/22/11.

Review of the History and Physical Examination dated 02/22/11 indicated Patient #2 was admitted with a Stage I pressure ulcer

Review of the Skin Risk Algorithm indicated a Stage I pressure ulcer is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to the adjacent tissue.

Review of the Nursing Assessment dated 2/23/11 at 7 PM indicated there was evidence of a pressure ulcer however there was no documented description of the pressure ulcer.

Review of the Nursing Assessment dated 02/24/11 indicated Patient #2 had a Stage 2 pressure ulcer and a DuoDerm dressing was between the buttock. There was no documented measurement of Patient #2's pressure ulcer.

Review of the Nursing Assessment dated 02/26/11 at 8 AM indicated Allevyn dressing was applied to the wound.

There was no documented comprehensive Wound Assessment for Patient #2.

Registered Nurse #5 was interviewed on 03/01/11 at 3 PM. RN #5 said Patient #2 had a quarter size pressure sore but the dressing was intact.

Continued review of Patient #2's medical record indicated there was no Wound Assessment documented. On 03/01/11, Patient #2 was discharged home with Hospice care.

Patient #3:

Patient #3 was hospitalized in November 11/07/10.

Patient #3 was admitted to the Hospital with no identified pressure ulcers.

Review of the Nursing Assessment dated 11/23/10 indicated Patient #3 developed a Stage 2 pressure ulcer. There was no documented measurement of Patient #3 pressure ulcer.

Review of Patient #3 medical record lacked any documented Wound Assessment.

Based on record review and staff interview two of three applicable medical records reviewed for Patients #1 and #3 who developed health care associated pressure ulcers while hospitalized in July 2010 and November 2010 respectively lacked appropriate and timely assessments of their wounds.
Patient #2 was admitted with Stage I pressure ulcer which deteriorated to a Stage 2. There were no documented Wound Assessments for three of three applicable patient records reviewed with Stage 2 pressure ulcers. There was no measurement or reassessment of the three of three Patients (#1, #2 and #3) with pressure ulcers at the time of discharge.

The findings are as follow:

Patient #1:

Patient #1 was admitted to the Hospital with intact skin without any evidence of a pressure ulcer.

Review of the Nursing Assessment documented on 07/26/10 at 8 AM indicated Patient #1's skin was inspected head to toe. The Nursing Assessment indicated the Integumentary (Skin) Findings were abnormal. The Nursing Assessment lacked further documentation as to the abnormal findings. Instead, the Nursing Assessment indicated to refer to the Wound Assessment. However, there was no Wound Assessment documented in Patient #1's medical record for the date of 07/26/10.

The Hospital's Risk Manager was asked to retrieve the Wound Assessment documentation dated 07/26/10 at 10 PM. The Hospital's Risk Manager said there was no documented Wound Assessment for Patient #1.

Continued review of the Nursing Assessment dated 07/26/10 at 10 PM indicated the coccyx wound dressing was changed to Patient #1's pressure ulcer. There was no documentation for the appearance, size nor staging of Patient #1's coccyx wound nor documentation of the surrounding skin. There was no nursing documentation as to the type of dressing applied to Patient #1's coccyx wound. There was no prior documentation of a Wound Assessment despite the application of a dressing to the coccyx wound. There was no documentation of staging, measurement or appearance of Patient #1 coccyx wound site.

Review of the Nursing Assessment dated 07/27/10 at 12 AM indicated Patient #1's coccyx was covered with an intact Mepilex dressing and the skin color was pale. Patient #1's heels were pink and elevated on a pillow.

Review of the Skin Risk Assessment dated 07/27/10 at 12 AM scored Patient #1's risk for skin breakdown as an 8. There was no documentation on the Skin Risk Assessment that Patient #1 had a pressure ulcer on the coccyx.

Review of the Nursing Assessment dated 07/27/10 at 8 AM indicated Patient #1's coccyx was covered with an intact Mepilex dressing and the skin color was pale. Patient #1's heels were pink and elevated on a pillow.

Registered Nurse (RN) #1 was interviewed on 03/03/11 at 9 AM. RN #1 conducted the Admission Nursing Assessment for Patient #1. RN #1 said Patient #1 was well cared for at home by a family member and there were no pressure sores present on admission to the Hospital. RN #1 said Patient #1 was at risk for the development of a pressure sore secondary to moist skin and lack of movement. RN #1 said Patient #1 needed to be turned every one to two hours, needed incontinent care with a waterless soap and the application of a barrier cream. RN #1 said Patient #1 developed a Stage 2 pressure ulcer on the coccyx close to the discharge date which never worsened. RN #1 said on 07/27/10 at 8 AM, the Mepilex dressing was intact so there was no need to remove the dressing. RN #1 said the Mepilex dressing could be placed on intact skin without the skin being broken down or open. RN #1 said the Nursing Assessment would have automatically triggered an action to complete a Wound Assessment.

Continued review of the Nursing Assessment dated 07/27/10 at 4 PM by RN #2 repeated the same language for the assessment conducted on 07/27/10 at 9 AM. Registered Nurse #2 documented Patient #1 coccyx pressure ulcer covered with an intact Mepilex dressing and the skin color pale. Patient #1's heels were pink and elevated on a pillow.

Registered Nurse #2 was interviewed in person on 03/03/11 at 12 PM. RN #2 said Patient #1's dressing was intact. RN #2 said the dressing would not have been removed. RN #2 said the Mepilex dressing can remain in place for two to three days.

Review of the Nursing Assessment dated 07/28/10 at 12 AM indicated Patient #1 had a Stage 2 pressure ulcer on the buttocks and Mepilex was intact. The medical record continued to lack an appropriate measurement of Patient #1's buttock pressure ulcer and documentation for the condition of the surrounding skin. The medical record continued to lack a documented Wound Assessment of Patient #1's pressure ulcer as per Policy.

Review of the Hospital's Skin At Risk Algorithm indicated A Stage II pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without sough. May also present as an intact or open/ruptured serum-filled blister. Presents a shiny or dry shallow ulcer.

On 07/29/10 at 12 AM and at 10 AM the Nursing Assessment indicated Mepilex times two on buttocks, (the pressure ulcer) reported as a Stage 2. Patient #1's heels pink, intact and elevated on a pillow. It was not specifically clear as to whether Patient #1's pressure ulcer had changed or deteriorated requiring two dressings; as there was no prior documentation for the appearance of Patient #1's pressure ulcer.

Registered Nurse #3 was interviewed on 03/03/11 at 3:20 PM. RN #3 was assigned to Patient #1 on 07/29/10 and documented the note on 07/29/10 at 10 AM. RN #3 said Patient #1's pressure ulcer must have been reported as a Stage 2 and the dressing would not have been removed; if the dressing was intact. RN #3 said the Wound Care Team generally documents the appearance of the patients pressure ulcer.

The VP of Nursing/Chief Nursing Officer was interviewed on both days of survey. The VP of Nursing said the Wound Care Team conducted prevalence studies quarterly whereby a team evaluated all patients with the exception of obstetrical patients each quarter for the presence of pressure ulcers. The Team then documented whether the patients pressure ulcers were present on admission or health care associated/hospital acquired. The VP of Nursing said each inpatient unit had trained nursing staff to utilize as a resource for the assessment of patients with pressure ulcers. The VP of Nursing said there were two Wound Nurse Consultants available to the staff and for the assessment of patients in need of consultation.

Documentation on 07/30/10 at 12 AM indicated the Nursing Assessment repeated the previous entry: Mepilex times two on buttocks, reported as a Stage 2. Patient #1's heels pink, intact and elevated on a pillow.

Documentation dated 07/30/10 and 07/31/10 indicated Registered Nurse #4 was assigned to Patient #1 during the 7 AM to 7 PM shift. The Nursing Assessment dated 07/30/10 at 9 AM indicated Mepilex times two on buttocks, reported as a Stage 2 on buttocks. Patient #1 heels pink, intact and elevated on a pillow.

Registered Nurse #4 was interviewed on 03/03/11 at 11 AM. RN #4 said on 07/30/10 Patient #1 was scheduled for a percutaneous endoscopic gastrostomy (PEG) tube insertion. RN #4 said because Patient #1 was going to the operating room, two dressings were changed on the buttock area. RN #4 said one area was reddened and the second area was open with black eschar on the edge. RN #4 said Patient #1 had a Stage III pressure ulcer. RN #4 documented Patient #1 had two Mepilex intact dressings on buttocks. RN #4 documented Patient #1 had pink, intact heels elevated on a pillow. RN #4 said a Wound Assessment was required to document Patient #1's pressure ulcer. RN #4 was scheduled to work the next day and intended to document Patient #1's pressure ulcer on 07/31/10. RN #4 said the Wound Assessment intervention was needed on 07/30/10 and RN #4 planned on documenting the Wound Assessment but did not have time. RN #4 was aware that a Wound Assessment was never documented and failed to conduct an immediate assessment for Patient #1 with a Stage III pressure ulcer. RN #4 did not notify a physician or request assistance from a clinical specialist to consult with the appearance, stage and measurement of Patient #1's coccyx/buttock wound.

Review of the Hospital's Skin At Risk Algorithm indicated Stage III presents as full thickness tissue loss involving damage or necrosis that may extend down to, but not through fascia. Clinically presents as a deep crater, with or without undermining and may be shallow if located on an area without significant fat.

Review of the Nursing Assessment for Patient #1 dated 07/31/10 at 10 AM, by RN #4 indicated a Stage 2 (versus a Stage III) pressure ulcer was located on the coccyx with a small amount of drainage and eschar noted in the center of the wound. RN #4 indicated the edges to the pressure ulcer were pink. RN #4 documented the area was cleansed with normal saline and covered the area with a Mepilex dressing.

Review of the Hospital's Skin At Risk Algorithm indicated an Unstageable pressure ulcer was defined as a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. When eschar is present, accurate staging is not possible until it is removed. If dry, black, it may need surgical (sharp) debridement. If moist, tan/yellow slough, debridement may be done autolytically, by enzymatic agents or mechanically by wet to dry dressing.

The Hospital's Skin At Risk Algorithm indicated with the presence of necrosis consult Skin and Wound nurse or the unit's skin specialist.

Review of the Wound Assessment as documented by RN #4 on 07/31/10 at 10 AM contradicted the documentation in the Nursing Assessment. RN #4 indicated Patient #1 had a coccyx pressure ulcer which was unstageable. RN #4 indicated the wound appearance had minimal, old, brown drainage with mild odor. RN #4 indicated the wound bed was pink. RN #4 indicated a documentary photograph was not taken.

Review of the Discharge Planning Note by RN #4 dated 07/31/10 at 1 PM indicated Patient #1's coccyx pressure ulcer measured 1 centimeter by 1 centimeter of eschar with surrounding pink tissue. RN #4 said the measurement referred to the center of Patient #1's pressure ulcer.

An additional Wound Assessment was documented on 07/31/10 at 2 PM by RN #4. RN #4 indicated Patient #1's coccyx pressure ulcer was unstageable. RN #4 documented the wound appearance was clean and dry (versus the previous assessment of minimal, old brown drainage with a mild odor) and the wound bed was pink. RN #4 indicated there was no drainage and the surrounding tissue was pink. RN #4 indicated a photograph was taken.

A Discharge Planning Note written on 07/31/10 at 6 PM by RN #4 indicated the measurement of Patient #1's pressure ulcer was 2.1 centimeters by 2.8 centimeters of eschar with minimal drainage and surrounding tissue was pink.

RN #4 said another nurse on the unit trained in measuring pressure ulcers photographed Patient #1's coccyx pressure ulcer and measured Patient #1's pressure ulcer.

A Documentary Photograph of Patient #1's coccyx pressure ulcer measured 2.1 centimeters by 2.8 centimeters. There was necrotic tissue in the center and slough surrounding the darkened area. The Documentary Photograph was incorrectly dated 07/20/10.

The Wound Nurse was interviewed on 03/03/11 at 12:30 PM. The Wound Nurse said a skin care team was formed several years ago. The Wound Nurse said training had been provided to staff on the inpatient units to assist in the assessment of patients with pressure ulcers. The Wound Nurse was not involved with Patient #1's assessment. The Wound Nurse said review of the Documentary Photograph indicated there were no signs of infection. The Wound Nurse said an autolytic debridement with dressing could have been attempted. The Wound Nurse said Mepilex dressing is absorptive and does not cause trauma when removed.

Review of the Medical Progress Note dated 07/31/10 at 11:59 AM indicated Patient #1 was positive for the development of sacral wound. There was no further documentation regarding the status of Patient #1's sacral wound. There was no documented wound consultation for the assessment of Patient #1's wound.

There was no discharge referral documentation by nursing for the description of Patient #1's pressure ulcer and it was not clear as to which Discharge Planning Note accompanied Patient #1 to the skilled nursing facility.

There was no evidence Patient #1 was evaluated by a qualified wound nurse and/or physician to determine the appropriate course of treatment and plan for Patient #1's wound care.

The Nurse Manager was interviewed person on 03/01/11 at 1:20 PM The Nurse Manager denied having any knowledge of patients with pressure ulcers on the inpatient unit.

A tour of the inpatient unit on 03/01/11 indicated Patient #2 had a Stage 2 pressure ulcer and was discharged.

Patient #2

Patient #2 was admitted to the Hospital on 02/22/11.

Review of the History and Physical Examination dated 02/22/11 indicated Patient #2 was admitted with a Stage I pressure ulcer

Review of the Skin Risk Algorithm indicated a Stage I pressure ulcer is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to the adjacent tissue.

Review of the Nursing Assessment dated 2/23/11 at 7 PM indicated there was evidence of a pressure ulcer however there was no documented description of the pressure ulcer.

Review of the Nursing Assessment dated 02/24/11 indicated Patient #2 had a Stage 2 pressure ulcer and a DuoDerm dressing was between the buttock. There was no documented measurement of Patient #2's pressure ulcer.

Review of the Nursing Assessment dated 02/26/11 at 8 AM indicated Allevyn dressing was applied to the wound.

There was no documented comprehensive Wound Assessment for Patient #2.

Registered Nurse #5 was interviewed on 03/01/11 at 3 PM. RN #5 said Patient #2 had a quarter size pressure sore but the dressing was intact.

Continued review of Patient #2's medical record indicated there was no Wound Assessment documented. On 03/01/11, Patient #2 was discharged home with Hospice care.

Patient #3:

Patient #3 was hospitalized in November 11/07/10.

Patient #3 was admitted to the Hospital with no identified pressure ulcers.

Review of the Nursing Assessment dated 11/23/10 indicated Patient #3 developed a Stage 2 pressure ulcer. There was no documented measurement of Patient #3 pressure ulcer.

Review of Patient #3 medical record lacked any documented Wound Assessment.

On 12/16/10, Patient #3 was discharged with no further reassessment of the pressure ulcer.