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Based on observation, interview, record review, and a review of the facility policy for pressure ulcers it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the care of a patient related to pressure ulcers for one (1) of ten (10) sampled patients (Patient #10). A suspected deep tissue injury was observed on Patient #10's coccyx on 02/14/16. The facility failed to assess and treat the area in accordance with established facility policy/procedure. The patient was observed to have a dressing to the area for an unknown period of time. Patient #10 developed a Stage II area with no evidence the area was documented and treated per the facility policy and no evidence a Registered Nurse supervised the care of the pressure ulcer.

The findings include:

Review of the facility policy/procedure for pressure ulcers titled "Skin Care, Assessment and Prevention," dated September 2014, revealed that a skin assessment was to be performed upon admission and every twelve hours. According to the policy the skin assessment was to be conducted head to toe, a front-to-back (every skin fold) examination of the skin surfaces both visually and by touch to observe for any alteration in skin integrity, and documented in the medical record.

Review of the medical record revealed the facility admitted Patient #10 on 02/08/16 with diagnoses that included Status Post Abdominal Surgery for a Pancreatic Pseudocyst, Anemia, Chronic Obstructive Pulmonary Disease, and Malnutrition. A review of the admission assessment for Patient #10 conducted on 02/08/16 at 8:00 PM revealed the patient was assessed to be alert and oriented, ambulatory, have no pressure areas, and to be at low risk for pressure ulcer development. A review of a photograph of Patient #10's coccyx taken on 02/14/16 at 4:32 PM revealed the patient had developed a pressure area to the coccyx. There was no other evidence of documentation of the pressure area in the medical record and no evidence the care of the pressure ulcer was supervised by a Registered Nurse.

A review of an incident report completed on 02/14/16 at 2:48 PM revealed the patient was observed with a Stage I pressure area on the coccyx. According to the report, the center of the area was purple skin that did not blanch surrounded by a pink area that was slow to blanch. Further review of the report revealed the patient was alert and oriented and able to reposition self, walked occasionally, and sat up in a chair occasionally. Nursing Staff and Patient Care Aides were to remind Patient #10 to turn and reposition on each round. Review of all skin assessments completed on Patient #10 each twelve hour shift from 02/08/16 to 02/21/16 revealed no evidence of any pressure area to the coccyx or evidence that wound care treatment was initiated to the area on the coccyx.

An interview conducted with Patient #10 during the initial tour of the facility on 02/22/16 at 11:25 AM revealed Patient #10 stated that he/she had a sore on his/her "bottom" and that the facility had placed a "patch" on the sore a few days earlier (Patient #10 could not recall the date). According to Patient #10 the sore was getting better.

An interview conducted with Licensed Practical Nurse (LPN) #1 on 02/22/16 at 4:40 PM revealed she was assigned to care for Patient #10 on 02/22/16 and had assessed Patient #10. LPN #1 stated she was not aware of any wound or dressing on the patient's coccyx.

Observation of a skin assessment conducted by LPN #1 on 02/22/16 at 4:45 PM revealed the patient had a four (4) inch by four (4) inch foam dressing to the coccyx. LPN #1 removed the foam dressing and a 1.0 by 0.5 centimeter Stage II pressure area with dry unstageable necrotic skin was observed to the patient's coccyx.

Interview on 02/22/16 at 4:45 PM conducted with LPN #1 revealed she was not aware of the dressing or the wound and had not provided any treatment and had missed the area on the patient's skin when she assessed the patient previously.

An interview conducted with LPN #2 on 02/23/16 at 12:50 PM who had provided care to Patient #10 on 02/21/16 revealed she was aware of dark redness to the patient's coccyx but was not aware of any dressing to the patient's coccyx. According to LPN #2 she had not documented the dark redness because she was busy with other patients and had forgotten to document or notify anyone.

An interview with Registered Nurse (RN) #1 on 02/23/16 at 11:05 AM revealed the RN had discovered the area on Patient #10's coccyx on 02/14/16 while conducting a skin assessment. According to the RN, the area was dark purple, was not open, did not blanch, and she thought the area was a suspected deep tissue injury. According to the RN she had taken a picture of the area and had reported the area on Patient #10's skin to the Clinical Supervisor, filled out an incident report, and instructed the Patient Care aides to remind the patient to turn and reposition when making rounds. According to RN #1 she did not do any treatment to the area or document the area on a skin assessment because she had completed an incident report. RN #1 stated she documented the area as a Stage I pressure area instead of a suspected deep tissue injury because the area was not open.

An interview with the Clinical Supervisor on 02/23/16 at 11:35 AM revealed that RN #1 reported to the Clinical Supervisor the pressure area on Patient #10's coccyx and the Clinical Supervisor instructed the RN to make sure everyone was aware of the area and that the Patient Care Aides reminded the patient to turn and reposition. Further interview with the Clinical Supervisor revealed she was not aware the patient had developed a Stage II pressure area to the coccyx that was not documented in the record until the area was discovered on 02/22/16.

An interview conducted with the Director of Nursing (DON) on 02/23/16 at 1:10 PM revealed she received the 02/14/16 incident report for Patient #10, and the incident report was discussed in the facility morning meeting on 02/15/16. The DON stated that the care initiated for the pressure area seemed appropriate. The DON stated she was behind on reviewing incident reports and had not closed the incident report or followed up to see if the area had been documented and treated per the facility policy/procedure. According to the DON, the area should have been documented in the Medical Record on the patient flow sheet and the patient's standing orders implemented for wound care and documented on the patient's treatment sheet.

Based on observation, interview, and medical record review it was determined the facility failed to develop and keep current the nursing care plan for one (1) of ten (10) sampled patients (Patient #10). Patient #10 developed a pressure area to the coccyx on 02/14/16 and there was no evidence the plan of care was revised with additional interventions to prevent further decline. The patient was observed with a dressing to the coccyx covering a Stage II pressure area and necrotic tissue on 02/22/16. There was no evidence of interventions on the patient's care plan to reflect any treatment to the pressure area on the patient's coccyx.

The findings include:

A review of the facility policy and procedure for care planning dated August 2015 revealed care and treatment were planned based on assessment results to ensure they were appropriate to the patient's needs. According to the policy, Registered Nurses will initiate an individualized plan of care based on identified patient problems/needs and were required to meet the patient care goals.

Review of the medical record revealed the facility admitted Patient #10 on 02/08/16 with diagnoses that included Status Post Abdominal Surgery for a Pancreatic Pseudocyst, Anemia, Chronic Obstructive Pulmonary Disease, and Malnutrition. A review of the admission assessment for Patient #10 conducted on 02/08/16 at 8:00 PM revealed the patient was assessed to be alert and oriented, ambulatory, have no pressure areas, and to be at low risk for pressure ulcer development. A review of the plan of care developed for Patient #10 with nursing diagnoses of risk for and/or impaired skin integrity revealed interventions to assess the skin every shift, assist the patient to turn/reposition every two hours, and manage friction/sheer by repositioning and lubrication.

Further review of the medical record revealed a pressure area was identified on the patient's coccyx on 02/14/16 by nursing staff. Interventions to encourage the patient to turn every two hours because the patient could self-turn and reposition were documented on an incident report. However, there was no evidence the patient's nursing care plan was updated with these interventions.

Observation of Patient #10's skin during a skin assessment on 02/22/16 at 4:45 PM revealed the patient had a 1.0 centimeter by 0.5 centimeter Stage II pressure area with dry unstageable necrotic skin to the patient's coccyx. The wound was covered with a four (4) inch by four (4) inch foam dressing.

A review of the plan of care for Patient #10 revealed no evidence the plan of care had been updated to include interventions for pressure ulcer treatment or monitoring of the Stage II pressure ulcer or the unstageable necrotic tissue.

An interview conducted with Patient #10 during the initial tour on 02/22/16 at 11:25 AM revealed Patient #10 stated that he/she had a sore on his/her "bottom" that the facility had placed a "patch" on a few days earlier (Patient #10 could not recall the date). According to Patient #10 the sore was getting better.

An interview with Registered Nurse (RN) #1 on 02/23/16 at 11:05 AM revealed the RN discovered the area on Patient #10's coccyx on 02/14/16 while conducting a skin assessment. RN #1 stated the area was dark purple, was not open, did not blanch, and she thought the area was a suspected deep tissue injury. RN #1 stated she took a picture of the area, reported the area on Patient #10 to the Clinical Supervisor, filled out an incident report, and instructed the Patient Care Aides to remind the patient to turn and reposition when making rounds. Further interview with RN #1 revealed she did not add the interventions to the plan of care or document the pressure area in the medical record because she may have forgotten.

An interview with the Director of Nursing (DON) conducted on 02/23/16 at 1:10 PM revealed when a patient develops a pressure area the nurse was required to assess the wound to include measurements, take a picture of the wound, document the finding in the patient's medical record, complete an incident report, and follow the standing wound care protocol for treatment. Further interview revealed the nurse was also required to review the patient's plan of care for interventions and develop additional interventions as necessary to ensure treatment to meet the needs of the patient.