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Based on interview and record review, the facility failed to develop nursing care plans for 2 of 10 patients (#4, #6) having skin care needs resulting in unclear treatment goals and interventions related to skin healing, as well as increasing the potential for poor clinical outcomes. Findings include:

Patient #4:

A review of Patient (Pt) #4's record began on 02/12/19 at approximately 1130 with the administrative nurse (RN B) present. The record contained the following information:

Pt #4 was a 60 year old male admitted to the hospital on 01/16/19 with gastrointestinal issues, as well as other issues. The wound care/ostomy notes written by the wound care/ostomy nurse (RN I) dated 01/21/19 indicated Pt #4 had a loop ileostomy (a surgical opening bringing the intestine to the outer skin surface) in the right lower quadrant of the abdomen with an appliance that was "constantly leaking despite few attempts to change it by the nurse in charge". Additional wound care notes written by RN I on 02/11/19 indicated Pt #4's ostomy appliance "has a leakage".

Also, a medical progress note written by the physician (MD R) dated 01/29/19 indicated, under the assessment and plan section, that Pt #4 had a scrotal blister and the wound care nurse would be consulted. Wound care notes written by RN I on 02/11/19 indicated Pt #4 had a 3 centimeter moist necrotic wound on the scrotal area.

Upon completion of this record review on 02/12/19 at approximately 1145, there was no evidence that a nursing care plan had been developed to address Pt #4's skin care needs related to the ileostomy or necrotic wound on the scrotal area.

Patient #6

A review of Patient (Pt) #6's record began on 02/13/19 at approximately 0915 with the administrative nurse (RN B) present. The record contained the following information:

Pt #6 was an 80 year old male admitted to the hospital on 02/02/19 with gastrointestinal issues, as well as other issues. The wound care/ostomy notes written by the wound care/ostomy nurse (RN I) dated 02/04/19 indicated Pt #6 had a colostomy (a surgical opening bringing the colon to the outer skin surface) in the lower left quadrant of the abdomen with a midline abdominal dressing that had moderate bloody drainage with no active bleeding. This note indicated that Pt #6 would be provided ostomy teaching "once he feels better".

Also, an order was entered on 02/03/19 to place Pt #6 on continuous Pressure Ulcer Prevention Measures. The record showed that over the course of stay, Pt #6 had been assessed to have Braden Scale scores ranging from 12 (high risk for skin breakdown) on 02/03/19 to 15 (low risk for breakdown) on 02/06/19.

Upon completion of this record review on 02/13/19 at 0940, there was no evidence that a nursing care plan had been developed to address Pt #6's skin care needs related to the colostomy or to address the pressure ulcer prevention measures.

During an interview with the wound/ostomy care nurse (RN I) on 02/12/19 at 1115, RN I indicated all registered nurses in the facility were expected to complete some degree of wound and ostomy care, however his job role was to focus on patients having more significant wound care and ostomy related needs. RN I indicated he completed assessments on patient as referred and documented needed interventions within the hospital documentation systems.

During an interview with the administrative nurse (RN B) on 02/13/19 at approximately 0930, RN B indicated the hospital electronic documentation system contained an area that allowed registered nurses to develop nursing care plans and enter this data into the record. RN B indicated within this area there were specific areas to address patient skin care needs, as well as areas to address other individual needs. RN B indicated it was the registered nurse's responsibility to enter this data in a timely manner specific to the individual needs of the patient.

During an interview with the nursing director (RN E) and administrative nurse (RN O) on 02/13/19 at approximately 1035, RN E acknowledged it was the registered nurse's responsibility to develop nursing care plans based on assessment findings as well as to create goals and interventions to be reviewed and edited as necessary to reflect the individualized needs of the patient.

A review of facility policy and procedure titled, "Patient Admission, Assessment/Reassessment and Care Plan Development" last approved April 2018 was completed on 02/13/19 at approximately 1100. This policy and procedure indicated, under purpose section, "A Registered nurse (RN) is responsible for the completion of this initial comprehensive assessment and care plan development". Also, under section 3. Care Plan Development, the policy and procedure indicated, "Assessment findings will be analyzed to facilitate formulation of the care plan including an education/teaching plan in consultation with patient/significant other. Specific care plans are activated based on assessment findings. Goals and interventions are to be reviewed and edited as necessary to reflect patients individualized needs", and "a. All data shall be recorded in the medical record ...".