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This Condition of Participation is not met based on a review of 3 clinical records, and interview with both administrative and clinical staff. The hospital failed to ensure the nursing services provided to patients demonstrated effective assessments and treatments. This failure places all patients with wounds of any type, including pressure ulcers, at risk for further deterioration and decline in wound status.

Refer to tag A0395 for specific details related to wound care to patients.

Based on a review of 3 clinical records, interview with administrative and clinical staff, the facility failed to ensure the assessment and evaluation of the patient resulted in preventative treatments, ongoing evaluations of pressure ulcer and the assessments of effectiveness of the treatment initiated for pressure ulcers 2 (Patients #1 and #2) patients developed.

The findings include:

1. Patient #2 was admitted to the hospital on 7/21/10 with intact skin. This patient had diagnoses that included chronic renal failure, polycystic kidney disease, history of cancer of the prostate; an old CVA (stroke) with right sided hemiparesis to the point the patient was unable to move the right side without help.

The nursing note dated 7/22/10 at 8 a.m. indicated the patient had an old "bed sore", that was closed and the nurse applied Lantiseptic to the area. There was no documentation about the patient's skin on 7/23/10. On 7/24/10, the documentation indicated the left side of the buttock was "excoriated." There was no specific observation of the skin to include a measurement of the excoriated area. On 7/25/10, the documentation in the nursing note indicated the right lower hip contained an open skin area, identified as stage 2. Documentation also indicated an old area on the sacrum had opened also. Documentation of the hospital's wound care specialist visit to did not take place until 7/26/10. The documentation in the wound care specialist note did not include any wound measurements but indicated she had explained to the patient the need to turn. The note further indicated the patient understood this instruction however, the patient speaks no English and there was no documentation indicating a translator was utilized for this instruction. The wound care nurse indicated during interview on 7/30/10 at 4:15 p.m. that she was aware the patient did not speak English but thought the patient understood the instructions.

Interview with the director of the nursing unit on 7/30/10 at 4 p.m., indicated the patient's care is determined by the Braden scale which is done for each patient. This patient had a Braden scale (a tool used to evaluate the patient skin status. The higher the score the less risk the patient has to develop a pressure ulcer. A score of 11-14 is regarded as a moderate risk for pressure ulcers) evaluation done every day. Based on this scoring, it is then determined the type of care the patient should received. Review of this patient's Braden scale indicated a daily scoring between 13 and 16. The director of the unit then explained further that the patient would be classified as at moderate risk and would have the following approaches initiated; "turning schedule, use of foam pillows for 30 degrees latter positioning, pressure reduction support surface, maximum remobilization, protect heels, manage moisture, nutrition, and friction/shear." The interventions further indicated if the patient had other major risk factors then advance the patient to the next level of care. There was no reassessment to evaluate this patient and initiated a higher level of interventions if needed.

When questioned about the documentation related to these interventions, the director further indicated the documentation would be noted in the nursing notes in the skin assessments section. This section had hourly documentation present with the first line for "Patient Rounds" and the second line as "repositioning." The documentation is entered as a check, but it could not be determined what the check in the box meant such as the patient was turned, pulled up in bed, placed in the chair. The nursing notes for 7/22/10 had no documentation in the check boxes for the period of 0700 (7:00 a.m.) through 1800 (6:00 p.m.) as noted in the note. The rest of the lines had an hourly check in both lines for patient's rounds and repositioning.

On 7/23/10, there was no documentation of an assessment of the skin and from 7 p.m. to 6 a.m. the documentation showed only a check mark.

On 7/24/10, the nursing note indicated the patient's skin was "escoriated skin opening" on the left buttock (reddened with potential open areas usually very small). There was no measurement or staging of this wound.

On 7/25/10, the nurse assessed the patient's skin located on the sacral area indicating an old "scab opened" and an area on the right hip which was open and pink. Again there was no documentation of size/measurements. There was no assessment of the excoriated area noted on the previous day's documentation. There was documentation of hourly rounds, and under repositioning it was noted as "self" with checks in the boxes.

On 7/26/10, the skin assessment in the nursing note revealed the sacrum was open, pink wound, and the right hip area was indicated as open. No note was made about the excoriated area on the left buttock. Again there was documentation indicating patient rounds had occurred. The positioning box had checks in it but could not be determined what turning had been done.

There was no assessment of the wounds on 7/27/10.

On 7/28/10, the nursing note indicated there was an excoriated area on the left buttock, a "denuded" area on the sacrum, and the skin tear "sheering" on the right hip. No mention of the wound to the right hip. The nursing notes for this date documented turning and positioning with pillows twice during this shift.

On 7/29/10, the nurse assessment of the skin included the "denuded excoriated" area on the left hip and sacrum, and the area identified as being a skin tear. There was no mention of the other areas as identified on 7/26/10.

Interview with the nurse caring for this patient on 7/30/10 indicated they are continuing to treat the areas with Lantiseptic. She indicated the patient's wounds are the same.

Review of the policy and procedure titled "Wound/Skin Care Protocol: Patients with Actual Impairment or At Risk for Alterations of Skin Integrity" was performed on 7/30/10. Included in this policy and procedure under daily wound assessment is "A. condition of current dressing
B. Drainage on current dressing.
C. Wound location stating specific anatomical site of each.
D. Wound type if known (e.g. pressure, venous, diabetic, arterial, traumatic, postop burn).
E. Wound stage, grade, depth, or degree.
F. Wound size, approximately length, width, and depth in centimeters.
G. Tunneling/Undermining.
H. Wound bed describe color of tissue, percentage of viable/non-viable tissue including periwound. Treatment to be specific."

There was no assessment to include size of any of the open or excoriated areas documented. There was no assessment of the effectiveness of any treatments performed for this patient.

2. Patient #1 was admitted to the facility on 7/4/10. The patient had acute vascular insufficiency and on 7/7/10 had a revascularization procedure. This patient also had acute respiratory deficiency, diabetes, hypertension, and chronic obstructive pulmonary disease. During this hospitalization this patient had the following procedures: 7/11/10 and 7/12/10 on each day an EGD (esophagoduodenostomy) procedures for acute gastrointestinal bleeding.

On 7/12/10, the patient had an exploratory laparoscopy with partial gastrectomy for continued bleeding. On 7/14/10, the patient had a right above the knee amputation. On 7/19/10 and 7/25/10 the patient had a bronchoscopy on each day. On 7/29/10, the patient had a thoracentesis (a needle placed into the lung sac to remove liquid).

On 7/13/10, the nursing notes indicated there was a stage 2 pressure ulcer on the coccyx pink in color and 2 by 2 in size. The day nurse on 7/14/10 assessed this pressure ulcer to be the same as on 7/13/10. On 7/15/10, the wound care nurse visited this patient. She documented the patient was in intensive care and intubated on a Stryker specialty mattress (this mattress rocks the patient from side to side while allowing the patient to remain on their back).

According to interview with the director of intensive care unit, at 3:15 p.m. on 7/30/10, this does not take the place of turning the patient but allows some changes in pressure to patients who cannot be turned. The wound care nurse indicated the pressure ulcer on the coccyx "has purple area with center superficial open area." "Initiated skin care protocol sheet that staff using Lantiseptic." The wound care nurse stated that as of 7/30/10, she had not "visualized" this wound at all.

On 7/15/10 on 7 p.m. to 7 a.m. shift the pressure ulcer was identified as being red 2 by 2 (no centimeters or inches notes).

On 7/16/10, 2 p.m. the nurse noted in the documentation that the patient had a "large decubitus on the coccyx 4 inch long by 2.5 inches wide at the thickest point. The open Stage II area is about 4 by 4 cm red and open." Lantiseptic applied liberally and a 4 by 4 dressing applied to pad area.

On 7/16-7/17/10 on the 7 p.m. to 7 a.m. shift, the nurse documented the coccyx/sacrum area was red & black and 2 by 2 in size. The next shift identified the area as red/black. There was no assessment done of the current treatment and no evaluation for an alternate treatment for this worsening pressure ulcer.

On 7/18 through 7/19/10 on 7 p.m. through 7 a.m. shift the nurse noted the pressure ulcer was purple and black, and the patient now had a reddened left heel. The nurse continued to document this wound on each shift through 7/21/10-7/22/10.

On the 7 a.m. to 7 p.m. shift on 7/22/10, the nurse noted the area was 3 by 3 inches.

Not until 7/25/10, did the nurse contact the wound care nurse and new care was initiated. At that time, although she had not seen the patient, the use of santyl (a medication that when applied to wounds will remove the blackened area) was initiated after obtaining orders from the physician. At the time of the survey on 7/30/10, the wound care nurse had not visited this patient and still had not visualized this wound. Although there were photos of the wound in the record, there was no accurate documentation of wound measurements. Based on the photo of 7/25/10, the pressure ulcer is now 15 cm by 11 cm in.

A review of the nursing notes for Patient #1 could not determine if the patient was turned and positioned, or if the patient was unable to be turned due to physical status. The use of the Stryker bed was documented throughout the patient's stay.

Interview with the Director of Intensive care on 7/30/10 at 3:15 p.m. revealed she agreed the nursing staff did not document or assess the pressure ulcer very well, and did not clearly document the preventative measure that were put in place once the patient developed a pressure ulcer.

Interview with the Chief Nursing Officer on 7/30/10 at 6:15 p.m. indicated the hospital had identified an issue in documentation and assessments of wound care. The facility is in the process of putting in place new documentation form which allows for clarification and improvement in the documentation of any type of wounds. The new process/form had not been implemented at the time of survey.