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Based on record reviews and interviews, the hospital failed to resolve a patient's grievance within a reasonable time frame with a written letter regarding the grievance investigation results for allegation alleged by the patient's caregiver "what poor care you people give" to S4RN on 10/27/11 and for the quality of care allegation alleged by another patient representative to the Director of Nursing (DONS2) on 10/28/11 at 2:00pm (1400) within 7 days of the allegation and within 72 hours of the hearing as per policy for 1 out 2 grievances reviewed (#2). Findings:

Review of the medical record for Patient #2 revealed she was admitted with the diagnosis of Depressive Disorder, Diabetes, GERD (Gastroesophageal Reflux Disease), Skin breakdown-buttocks and right heel, Bilateral lower extremity paralysis, Urinary Tract Infection, Constipation, Hypertension, Osteoarthritis, Foley Catheter, Incontinent of bowel, and other diagnosis. She was admitted to the hospital at 5:45pm (1745) on 10/12/11 and discharged to home on 10/27/11 at 9:45am (0945).

Review of the grievance folder revealed there was a "Grievance Form" dated/timed 10/28/11 at 2:00pm (1400). There was handwritten documentation written on the back of the form by S2DON. Further review of the form revealed S4RN (named) reported Patient #2's "care giver" (the patient's caregiver named) called and instructed her (S4RN) that the state was going to be notified of "what poor care you people give" on 10/27/11. There was no time documented that S2DON recorded the allegation reported from S4RN on 10/27/11 on the "Grievance Form" as per policy. Further review of the "Grievance Form" revealed another complaint was filed per another patient representative who stated, "we had to take her (the patient) to the hosp (hospital) last night and they took pictures...now she has to go to the wound care center" on 10/28/11 at 2:00pm (1400).

Further review of the "Grievance" folder revealed there was no documentation of a written letter of the grievance investigation that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for the allegation of "what poor care you people give" alleged by the patient's caregiver to S4RN on 10/27/11 and/or for the quality of care alleged by the other patient's representative to the Director of Nursing (DONS2) on 10/28/11 at 2:00pm (1400) within 7 days of the hearing as per policy.

During an interview on 01/03/12 at 10:30am, S2DON confirmed the patient's (#2's) caregiver (named) alleged a complaint to staff, S4RN on 10/27/11. The DON indicated that she was unable to contact the caregiver (named) on 10/27/11. S2DON verified she contacted another patient representative on 10/28/11 at 2:00pm (1400). S2DON indicated the other patient (#2) representative alleged a complaint regarding the quality of care the patient received at the hospital. The DON verified she did not to notify the supervisor (S1Administrator) of the incident on 10/28/11 as per policy. S2DON indicated the complainant (the other representative named) did not want any follow-up of the complaint. The DON continued the other representative named for the patient (#2) did not want any more contact with the facility. S2DON confirmed there was no documented evidence on the "Grievance Form" dated/timed 10/28/11 at 2:00pm (1400) and/or in the "Grievance" folder that the other patient's (#2's) representative (named) did not want a follow-up of the complaint investigation conducted by the hospital, S2DON. Further S2DON verified there was no documentation of a written letter to Patient #2's "caregiver" (named) and/ the other patient representative (named) regarding the grievance investigation results completed within 7 days by the DON as per policy.
In an interview on 01/03/11 at 11:10am, the Administrator (S1) indicated there was no formal complaint filed for the patient (#2) during her hospital stay from 10/12/11 through 10/27/11. The Administrator indicated there was a complaint alleged after the patient (#2) was discharged from the hospital. S1 confirmed there was no letter written to the patient's representatives (named) regarding the grievance investigation results of the allegations from patient's (#2's) caregiver (named) on 10/27/11 to S4RN or from the other patient representative (named) on 10/28/11 at 2:00pm. S1Administrator indicated this grievance is still in the process of a hearing according to policy.
The policy titled, "RTS-04 Complaint/Formal Grievance Procedures", Adopted date of March 2009, Revised date of April 2009, with no last reviewed date, presented on 01/03/12 at 11:40am by the Administrator (S1) as the hospital's current "Compliant/Grievance" policy was reviewed. The policy indicated the Department Supervisor schedules a hearing with patient and/or family member for the purpose of conducting an informal, but thorough, investigation of the allegation to determine its validity affording all interested persons and their representative, if any, an opportunity to submit evidence relevant to the allegation. The Department Supervisor issues a written decision which includes the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion within 7 days of the hearing. If no resolution occurs at this level, the investigation is not complete, or if the corrective action is still being evaluated, the hospital's response should address that the hospital is still working to resolve the complaint and states that the hospital will follow-up with another written response within so many days depending on the actions the hospital has to take.

Based on record reviews (Complaint/Formal Grievance Procedure, Grievance Log) and staff interviews, the hospital failed to inform the complainant in writing of the results of the grievance investigation that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for the allegation of "what poor care you people give" alleged by the patient's (#2's) caregiver to S4RN on 10/27/11 and/or for the quality of care issue alleged by another patient representative to the Director of Nursing (DONS2) on 10/28/11 at 2:00pm (1400) within 7 days of the hearing as per policy for 1 of 2 grievances reviewed, (#2). Findings:

Review of the grievance folder revealed there was a "Grievance Form" dated/timed 10/28/11 at 2:00pm (1400) read in part, " ...S4RN (named) reported to me "care giver" (named) of Patient #2 (named) called ...instructing her (S2DON) the state was going to be notified of "what poor care you people give" - S4RN (named) offered to let her (caregiver named) speak /c (with) her supervisor (S2DON) but she refused and hung up. I (S2DON) attempted @ (at) intervals to call the residence but the line was cont (continuously) busy. I (S2DON) attempted again after hours at my home and was instr (instructed) by another patient representative that the (caregiver named) had gone for the day. 10/28/11 10:40am (1040) attempted to call (a phone number was written) /s (without) answer. 10/28/11 1:45pm (1345) busy 10/28/11 2:00pm (1400) - complaint filed per (another patient representative named) who states "...we had to take her to the hosp (hospital) last night and they took pictures...now she has to go to the wound care center...". Further review of the "Grievance" folder revealed there was no documentation of a written letter to the caregiver of the patient and/or the other patient representative with the results of the investigation that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for "what poor care you people give "alleged by the patient's caregiver to S4RN on 10/27/11 and/or for the quality of care alleged by another patient representative to the Director of Nursing (DONS2) on 10/28/11 at 2:00pm (1400) as per policy.

During an interview on 01/03/12 at 10:30am, S2DON indicated the patient's (#2's) caregiver (named) alleged a complaint to staff S4RN on 10/27/11. The DON was unable to contact the caregiver (named) on 10/27/11. S2DON contacted another patient representative (named) on 10/28/11 in which a complaint was alleged regarding the quality of care the patient (#2) received at the hospital. S2DON did not to notify the supervisor (S1Administrator) of the incident as per policy. S2DON indicated the other patient representative (named) did not want any follow-up of the complaint. The DON continued the other representative (named) did not want any more contact with the facility. S2DON confirmed there was no documented evidence on the "Grievance Form" dated/timed 10/28/11 at 2:00pm (1400) that the caregiver and/or the other patient representatives for Patient #2 did not want a follow-up of the complaint investigation alleged on 10/27/11 and/or 10/28/11. The DON (DON) reported that she investigated the quality of care issues alleged by the other patient (#2) representative on 10/28/11. S2DON confirmed there was no documentation of the quality of care issues reported by the other representative for Patient #2 on the "Grievance" Form dated/timed 10/28/11 at 2:00pm (1400). The DON reported during her investigation of the quality of care issues reported by the other patient representative (named), she (S2) reviewed the patient's medical record, looked at the heel assessments of the patient for 10/12, 10/16, and 10/22. She (S2DON) indicated she did not see any changes in the patient's (#2's) skin during her investigation and/or record review except she identified there was a problem with the wound descriptions documented by the RNs. S2DON stated she instructed the nursing staff that she wanted pictures of wounds on admit and if there are changes in the patient's skin. S2DON confirmed the nursing staff was in-serviced on the skin/wound care on 11/01/11 and 11/03/11.
In an interview on 01/03/11 at 11:10am, the Administrator (S1) indicated there was no formal complaint filed for the patient (#2) during her hospital stay from 10/12/11 through 10/27/11. S1 further indicated the chart was followed closely due to the involvement of Adult Protective Services. S1 stated a caregiver of the patient called and voiced a complaint the same day after the patient (#2) was discharged from the hospital. The family's complaint concerned the quality of care given while the patient (#2) was in the facility. During the investigation, they (the DON and S1Administrator) did not identify any problems as a result of the investigation. S1Administrator confirmed there was no written letter to the caregiver and/or the other patient (#2) representative (named) regarding the investigation allegations on 10/27/11 to S4RN and/or on 10/27/11 at 2:00pm (S2DON). This grievance is still in the process, a hearing, according to policy. There is no letter written to the patient's (#2's) caregiver and/or other patient representative regarding the grievance investigation until the hearing is completed according to policy.
The policy titled, "RTS-04 Complaint/Formal Grievance Procedures", Adopted date of March 2007, Revised date of April 2009, with no last reviewed date, presented on 01/03/12 at 11:40am by the Administrator (S1) as the hospital's current "Compliant/Grievance" policy was reviewed. The policy indicated the patient has the right to file a complaint. The patient must address the complaint with a staff member. If the issues resolution requires interdepartmental resources, the patient or family may verbally (or in writing) bring issues to the primary RN. At this point, the complaint becomes a formal grievance and the formal grievance form will be initiated. The Department Supervisor schedules a hearing with patient and/or family member for the purpose of conducting an informal, but thorough, investigation of the allegation to determine its validity affording all interested persons and their representative, if any, an opportunity to submit evidence relevant to the allegation. The Department Supervisor resolves or investigates the validity of the grievance within 48 hours of receipt of the grievance. The Department Supervisor issues a written decision which includes the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion within 7 days of the hearing. If no resolution occurs at this level, the investigation is not complete, or if the corrective action is still being evaluated, the hospital's response should address that the hospital is still working to resolve the complaint and states that the hospital will follow-up with another written response within so many days depending on the actions the hospital has to take.

Based on record reviews, policy reviews, and staff interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the care of each patient as evidenced by:
1) failing to ensure the skin assessments of the patient's wounds included the wound description documented for: a) Patient #2's Stage II to the right and left buttocks area(s) and right heel bruising on 10/12/11, 10/16/11, 10/22/11 and 10/27/11. The Stage II's pressure areas of the right and left buttocks and right heel bruising did not include the following information per the "Skin/Wound Care" policy: wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin, b) Patient #1's skin tear to the buttocks area on 10/14/11 did not include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin for 2 of 2 patient's records reviewed for who had pressure areas out of a total of 5 sampled records reviewed;
2) failing to perform the weekly skin assessment for Patient #2 as evident by not having documentation of a skin assessment performed on 10/15/11 for 1 of 5 sampled records reviewed;
3) failing to ensure the "Daily Skin Assessment and Bath Sheet" form(s) included the assessment of the patient's skin by the nursing staff during their shift as evidenced by not having documentation of the patient's (#2's) skin on 10/12/11, 10/14/11, 10/15/11, 10/16/11, 10/17/11, 10/18/11, 10/19/11, 10/20/11, 10/21/11, 10/23/11, 10/24/11, 10/25/11, 10/26/11, and 10/27/11 for 1 of 5 sampled records reviewed;
4) failing to notify the physician of changes in Patient #2's skin conditions regarding wounds, bruising and/or blisters for the following dates: 10/17/11, 10/18/11, 10/19/11, 10/21/11, 10/22/11, 10/23/11, 10/24/11, 10/26/11, and 10/27/11 for 1 of 5 sampled records reviewed; and
5) failing to perform a "Braden Scale For Predicting Pressure Sore Risk" assessments of the patient with a score of less than 18 for Patient #2 on the following dates: 10/13/11, 10/14/11, 10/16/11, 10/17/11, 10/18/11, 10/19/11, 10/20/11, 10/21/11, 10/23/11, 10/24/11, 10/25/11, 10/26/11 as per the "Skin/Wound Care" policy for 1 of 2 focused records reviewed for pressure area(s) out of a total of 5 sampled records reviewed.
Findings:
1)
Patient #2
Review of the medical record for Patient #2 revealed she was admitted for depressive disorder on 10/12/11 at 5:45pm (1745).

Review of the "Reason for Assessment" form revealed there were four (4) views of a person. There was a front view of a person, two (2) side views of a person ( a left and a right), and back views of a person and front, side, and back views of feet. Further review revealed a data key scale. The scale had letters "A" through "J". Further review of the scaled revealed the following information: the letter "A" indicated an abrasion, the letter "B" indicated a bruise, the letter "C" indicated a skin tear, the letter "D" indicated a laceration, the letter "E" indicated a pressure wound, the letter "F" indicated redness, the letter "G" indicated a rash, the letter "H" indicated well-healed scar, the letter "I" indicated a tatoo, and the letter "J" indicated other specify.

Review of the "Nursing Initial Skin Assessment" dated 10/12/11 with no time documented that the assessment was performed by the Director of Nursing (DON) S2 revealed Patient #2 had a "right (R) heel Pressure Wound cannot stage, well-healed scars to the abdomen area, two (2) area(s) to the back, reddened excoriated (rash-like) above the left buttocks area, bruises to the right forearm and elbow areas, and two (2) open areas Stage II Pressure Wounds on the right buttocks area and one (1) "open area Stage II Pressure Wound" to the left buttocks area.

Review of the "24 Hour Assessment/Reassessment" section titled, "Integumentary" dated/timed 10/12/11 at 5:45pm (1745) by the Registered Nurse (RN), S3 read in part, Patient #2 had a "(R) heel blood bruise" and "Stage II multiple buttocks". Further review of the "Wound Flowsheet" section on the form revealed she (#2) had "two (2) Stage II wounds to the right buttocks area(s) and one (1) Stage II wound to the left buttocks area". Both the "left and right Stage II wounds to the buttocks area(s) had duoderm dressing(s)" in place as indicated by the RN, S3 on the form. There was no documentation of the wounds description documented for the right heel blood bruise and/or Stage II multiple to buttocks area(s) that included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per policy.

In an interview on 01/03/12 at 8:52am (8:52 a.m.), S3RN verified she provided Patient #2 nursing care during the night shift from 6:00pm (6:00 p.m.) through 6:00am (6:00 a.m.) on 10/12/11. S3RN confirmed she performed the "Initial Assessment" of the patient. She (S3RN) indicated she looked at the patient's (#2's) skin and performed a quick skin assessment of the patient at 5:45pm (1745). S3RN stated Patient #2 had multiple wounds on her bottom. About an hour later, she looked at the patient's (#2's) skin when she assisted the MHT to clean the patient. S3RN reported Patient #2 had a "Stage II on sacrum and heel, and Stage II to right and left buttocks area(s). S3RN further reported the patient (#2) had multiple pressure sores. There was some redness around the area. S3RN indicated she did the skin assessment of Patient #2 but she did not measure the wounds. She had no measuring device to measure the wounds. The RN (S3) reviewed the "Skin/Wound Care Protocol" policy at this time. S3RN stated she failed to include the wound description documentation of the size, width, depth, drainage or odor as per policy. Further S3RN indicated she anticipated that photographs of Patient #2's wounds would be taken by the wound nurse and an ongoing assessment of the patient would be done in the morning. S3RN confirmed there were no photographs of Patient #2's wounds noted in the medical record. S3RN indicated she did the initial admission assessment of the patient (#2), but not the initial skin assessment of the patient. S3RN further indicated the wound nurse would have done the initial skin assessment of the patient (#2).

During an interview on 01/03/12 at 10:30 a.m., the Director of Nursing (DON) S2 verified she performed the "Initial Nursing Assessment" of Patient #2's skin on 10/12/11. The DON confirmed Patient #2 had "right (R) heel Pressure Wound cannot stage, well-healed scars to the abdomen area, two (2) area(s) to the back, reddened excoriated (rash-like) above the left buttocks area, bruises to the right forearm and elbow areas, and two (2) open areas Stage II Pressure Wounds on the right buttocks area and one (1) "open area Stage II Pressure Wound" to the left buttocks area. S2DON indicated she failed to describe and measure the wounds to Patient #2's right heel, and two (2) open areas Stage II Pressure Wounds on the right buttocks area and one (1) open area Stage II Pressure Wound to the left buttocks area as per the "Skin/Wound Care" policy.

Review of the "24 Hour Assessment/Reassessment" form section titled, "Integumentary" dated 10/15/11 and 10/16/11 revealed the nursing staff (S6RN, S7RN) assessed the patient (#2) with "Stage II to buttocks" area and "bruising to the right heel". There was no documentation documented for the right heel bruise and/or Stage II to the buttocks area that included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

Review of the medical record revealed there was no weekly skin assessment documented on the "Reason for Assessment" form performed by the RN on Saturday, 10/15/11 for Patient #2 as per protocol.

Review of the "Reason for Assessment Weekly" form that had the date, 10/15/11, written on the top of the page. The form was signed by S7RN on 10/16/11. Further review of the form revealed there were front and back view(s) of a person and a left and right view of a person on the form. There were views of the left, right and front and back of the feet. Further there was a Data Key box that included letters "A" through "J" indicating an abrasion (A), bruise (B), skin tear (C), laceration (D), pressure wound (E), redness (F), rash (G), well-healed scar (H), tattoo (I), and other (J). There was a second box located underneath the "Data Key" box that read, "Use the space below to provide further documentation of any changes. All pressure wounds require measurement of length, width, depth and staging". Further review revealed there was a section below both the "Data Key" box and the diagram of the front and back views of the person that read, "Finding Code" and "Description of Finding". Review of the "Description of Finding" section revealed the patient (#2) had "buttocks red /c several open areas", and "bruising to bilat hands and forearms". Patient #2 was documented with "posterior right heel purple area cannot stage". Further review of the "Finding Code" section on the form revealed this section was left blank. There was no documentation of the "buttocks red /c several open areas noted" that included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

In an interview on 01/03/12 at 9:18am, S6RN verified she provided Patient #2 nursing care during her shift on 10/15/11. S6RN indicated the night shift performs the weekly skin assessment of the patients every Saturday as per protocol. S6RN denied performing the weekly skin assessment for Patient #2 during her shift on 10/15/11.

During an interview on 12/29/11 from 10:20am to 10:50am, S7RN confirmed she provided nursing care to Patient #2 during her night shift on 10/15/11. S7RN indicated she did not perform the weekly skin assessment of Patient #2 as scheduled on 10/15/11. S7RN verified assessing Patient #2 with "Buttocks red /c several open areas noted...Bruising to bilat hands and forearms" during her assessment of the patient as documented on the "Weekly Assessment" form of the patient. S7RN confirmed the "Reason for Assessment Weekly" form had 10/15/11 written on the top of the page. S7RN indicated this assessment of Patient #2 was not performed until the following day, 10/16/11 due to several incidents (two) that had occurred during the night shift. Further S7RN indicated 10/15/11 was the scheduled date that the skin assessment of Patient #2 was to be performed. Patient #2's weekly skin assessment was not performed as scheduled on 10/15/11 as per protocol. S7RN denied what the policy stated regarding the wound description documentation for pressure areas. S7RN read the policy titled, "NSG-35 Skin/Wound Care Protocol" at this time. S7RN stated she failed to follow the policy for the wound description of Patient #2's "buttocks with several open areas" to include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin on 10/16/11.

In the same interview on 01/03/12 at 10:30am, the DON S2 confirmed there was no weekly Saturday skin assessment for Patient #2 dated 10/15/11 as per protocol. The DON verified S7RN performed Patient #2's skin assessment on 10/16/11. S2DON verified Patient #2 was assessed with "buttocks red /c several open areas" by S7RN on 10/16/11. S2DON indicated S7RN failed to describe and document Patient #2's "buttocks with several open areas" to include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin on 10/16/11 as per policy.

Review of the "24 Hour Assessment/Reassessment" dated 10/22/11 revealed she (#2) had "buttock red /c several open areas" and "blister (L) heel" documented by S4RN at 8:00am (0800). There was no documentation the nurse, S4 assessed Patient #2's buttock red with several open areas and/or left heel blister to include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per policy.

In an interview on 12/29/11 from 1:10pm through 2:10pm, S4RN verified she provided Patient #2 nursing care during the day shift from 6:00 a.m. to 6:00 p.m. on 10/22/11. S4RN denied performing the weekly skin assessment of Patient #2 during her shift on 10/22/11. S4RN indicated all weekly skin assessments are performed by the night nurses during bath/showers as per protocol.

Review of the "Reason for Assessment" sheet with no documentation of the reason the assessment for Patient #2 was performed by S5RN on 10/22/11 read, "Stage II (R) buttock(,) small scattered lesions coccyx(,) (L) ischial wound(,) (L) heel /c 2 boggy areas". Further review of the diagram revealed there was no documentation of the pressure wound description documentation for the patient's (#2's) Stage II (R) buttock(,) small scattered lesions coccyx, left ischial wound, and/or left heel with two (2) boggy areas that included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy. Further there was no documented evidence the physician was notified of the patient's left ischial wound assessed by S5RN on 10/22/11 as per protocol.

In the same interview on 01/03/12 at 9:50 a.m., S5RN verified she performed the weekly Saturday scheduled skin assessment of Patient #2 during her night shift from 6:00 p.m. to 6:00 a.m. on 10/22/11. She (S5) confirmed she assessed Patient #2 with "Stage II (R) buttock(,) small scattered lesions coccyx(,) (L) ischial wound(,) (L) heel /c 2 boggy areas" on 10/22/11. S5RN indicated there was no documented evidence Patient #2's pressure wounds to the right buttock area, small scattered lesions to coccyx area, left ischial wound and/or left heel were described to include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per policy.

During the same interview on 01/03/12 at 10:30 a.m., the DON S2 verified Patient #2 was assessed by S5RN with "Stage II right buttock, small scattered lesions coccyx, left ischial wound, and left heel with 2 boggy areas" on 10/22/11. S2DON indicated S5RN failed to describe and document the patient's (#2's) Stage II to right buttocks area, small scattered lesions to coccyx area, left ischial wound, and/or left heel to include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin during the weekly skin assessment of the patient as per policy.

Review of the "24 Hour Assessment/Reassessment" dated 10/27/11 revealed Patient #2 had "buttock red /c several open areas" and "blister (L) heel" documented by S4RN. Further review revealed there was no documented evidence the wound description of the buttock red with several open areas and/or left heel blister included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

Review of the "Reason for Assessment: Discharge" form dated 10/27/11 with no time documented that the assessment was performed by S4RN read in part, "resolving Stage II to buttocks area(s); blisters on bilateral heels". Further review revealed the patient (#2) had two (2) Stage II to both the left and right buttocks area(s) as indicated on the back buttocks area according to the diagram of a body pictured on the form. There was no documentation of the wounds descriptions for the left and right buttocks areas and/or blisters on both heels that included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

In the same interview on 12/29/11 from 1:10 p.m. through 2:10 p.m., S4RN verified Patient #2 had "buttock red /c several open areas" and "blister (L) heel" documented at 6:45 a.m. (0645). S4RN confirmed during the "Discharge Assessment" of Patient #2 she (S4) documented the patient with "resolving Stage II to buttocks area(s); blisters on bilateral heels; two (2) Stage II to the left and right buttocks area(s)". S4RN indicated she failed to accurately document the discharge assessment of Patient #2's buttock and heels to include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per policy. Further S4RN indicated she performed an inaccurate assessment of the patient's (#2's) heels and/or at the time of discharge because the patient had a blister to the left heel documented by her at 6:45 a.m. and the patient had blisters to both heels noted at the time of discharge.

During the same interview on 01/03/12 at 10:30 a.m., S2DON verified Patient #2 had "buttock red /c several open areas" and "blister (L) heel" documented at 6:45 a.m. (0645) by S4RN. The DON (S2) confirmed the "Discharge Assessment" of Patient #2 by S4RN was documented as the patient (#2) with "resolving Stage II to buttocks areas; blisters on bilateral heels; and two (2) Stage II to the left and right buttocks areas. S2DON indicated S4RN failed to document the discharge wound description of Patient #2's buttocks red with several open areas and/or blisters to both heels included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

Review of the medical record from hospital "a" dated 10/27/11 revealed there were photographs of the patient's (#2's) skin taken at 1:45 p.m. (1345) read in part, "...Stage III to right buttocks measuring 1.5 x (by) 3 centimeters (cm), an unstageable 2.3 x 1.4 cm; an unstageable left buttocks measuring 8 x 8 x 3 cm; left heel blister measuring 5 x 6 cm; right heel DTI (deep tissue injury) measuring 2 x 2 cm ; right medial heel DTI measuring 0.7 x 0.5 cm.

Review of the record from facility "b" revealed Patient #2 was assessed on 10/12/11 with "Stage II to RT (right) buttocks/sacrum area /c redness & excoriation noted" with no documentation of the pressure wound to the buttocks/sacrum area to include the length and width. Further review revealed on 10/28/11 Patient #2 was admitted with two (2) Stage II to the left ischial measuring 3.5 (3 1/2) x 2.5 cm, right buttocks measuring 2.3 x 2.2 mm (milliliters), right heel blister measuring 1.5 (1 1/2) x 1 with no documentation of the measurement(s) of mm and/or cm used, and left heel blister measuring 3.75 (3 3/4) x 2.5 (2 1/2) mm.

Patient #1
Review of the medical record for the patient (#1) revealed she was admitted for increased confusion, lots of recent stressors (lost her mother), fell, and health decline on 10/14/11. Review of the "Nursing Initial Assessment" dated 10/14/11 revealed the patient (#1) had a small skin tear noted to the buttocks area upon admission documented by S5RN. Further review revealed there was no wound description documented for Patient #1's small skin tear to the buttocks area that included the location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

During the same interview on 01/03/12 at 9:50 a.m., S5RN verified she provided Patient #1 nursing care on 10/14/11. S5RN confirmed she performed the initial skin assessment of the patient (#1) on 10/14/11. S5RN denied knowledge of a pressure wound policy. S5RN reviewed the "NSG-35 Skin/Wound Care Protocol" policy at this time. S5RN indicated she failed to describe Patient #1's skin tear to the buttocks area to include the wound description as per the "Skin/Wound Care" policy.

In an interview conducted on 12/27/11 from 10:40 a.m. to 11:20 a.m. and on 12/28/11 at 11:05 a.m., the DON, S2 verified Patient #1 was admitted to the hospital on 10/14/11 and assessed by S5RN with a small skin tear to the buttocks area that did not include the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per policy. S2DON indicated there was no documented evidence of a wound description for the patient's (#1's) skin tear to the buttocks area that included the wound's location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, and/or surrounding skin as per the "Skin/Wound Care" policy.

The policy titled, "NSG-02:Documentation", August 2011, with no revised and/or reviewed date(s), presented as the hospital's current "Nursing Assessment Documentation" policy on 12/28/11 at 9:50am by the Administrator, S1 was reviewed. Further review revealed the policy indicated nursing service personnel document on the daily nurse's note and in the integrated progress notes. Document every shift, incorporating the elements of the nursing process. One purpose of the documentation is to provide specific information regarding observations which reflect the care and progress of the patient. See specific comprehensive assessment the nursing section of specifics on assessment information. The documentation of an inpatient by the RN documents on the daily nurse's note a minimum of once per shift at the time any pertinent event occurs (may utilize integrated progress notes if additional space is needed). Documents pertinent, factual information, including assessment and outcome. Documents to reflect the overall treatment of each patient and actions implemented.

Review of the hospital policy titled, "Skin/Wound Care Protocol", NSG-35, August 2011, with no revised and/or reviewed date(s) and submitted by the Administrator, S1, as the current policy for assessments, revealed, in part, "...All patients admitted to Oceans Behavioral Hospital will be evaluated using the Braden Scale Risk Assessment. The assessment will be used throughout the patients stay as needed (prn) as patient activity changes. If the Braden score is less than 18, the hospital's Prevention Protocol will be implemented...Wound Care Protocols will be implemented whenever applicable ...RN...Will assess the patient's skin for alteration in integrity and risk for breakdown on admission...Will implement Prevention Protocol if Braden score is < (less than) 18 and will reassess geriatric patients daily...Refer to Prevention Protocol...Wound description documentation will include location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, surrounding skin...Wound description will be documented during the weekly reassessment...

Wound Assessment:

A. Staging of Pressure Ulcers (Only pressure ulcers can be staged):

Stage I: Nonblanchable erythema of intact skin. In individuals with dark skin, indicators may
also include discoloration, warmth, edema, induration or hardness.

Stage II: Partial thickness skin loss involving epidermis, dermis or both; ulcer is superficial
and presents abrasion, blister or shallow crater.

Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that
may extend down to, but not through, underlying fascia; may or may not have
undermining.

Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to
muscle, bone or supporting structures (e.g. tendon, joint, joint capsule); may have
undermining or sinus tracts.

Deep Tissue Injury: Deep discoloration to intact skin evident of injury to deeper tissue levels.
When eschar is present, accurate staging of the pressure ulcer is not
possible until the eschar has sloughed or the wound has been debrided.

For all other wounds, the following terms are used:

Superficial: Involves the epidermis only.
Partial Thickness: Involves the epidermis and some dermis.
Full Thickness: Involves all epidermis and dermis, and is into subcutaneous tissue, muscle
or bone...

B. Wound Assessment:
Measure the wound in centimeters weekly and record using clock descriptions.
Length is considered from 12 o ' clock to 6 o ' clocks.
Width is considered to be the distance from skin surface to bottom of wound bed.
(Measure depth by inserting sterile swab into wound, placing gloved finger on swab at
skin level, then placing swab next to a measuring guide.)
C. Drainage (Exudate):
Amount: Dry, scant/small, moderate or large.
Characteristic: Serous, sanguineous, serosanguineous, purulent, thin or thick, clear, red,
yellow, tan, green, foul odor.
D. Wound Bed Description:
Epithelial tissue: Pearly pink
Granulation: Beefy, red, shiny
Necrotic: Slough: Yellow, gray, green, black, white
Eschar: Thick, black, leathery...

Prevention Protocol...
1. Skin Risk Assessment using Braden Scale will be performed upon admission.
2. If score is less than 18, nurse will reassess patient weekly and prn. Prevention protocol will be instituted for patients with a score of less than 18...

Intact Skin-Patient At Risk:
...Inspect skin daily, paying particular attention to the bony prominences and feet. (Common sites of pressure ulcers: ...hips, sacrum, coccyx, ...heels)...".

2)
Patient #2
Review of the hospital policy titled, "Skin/Wound Care Protocol", NSG-35, August 2011, with no revised and/or reviewed date(s) and submitted by the Administrator, S1, as the current policy for assessments, revealed, in part, "...RN...Will assess the patient's skin for alteration in integrity...and risk for breakdown on admission...Will implement Prevention Protocol and will reassess geriatric patients daily...Refer to Prevention Protocol...Prevention Protocol...1. Skin Risk Assessment using Braden Scale will be performed upon admission.
2. If score is less than 18, nurse will reassess patient weekly and prn...".

Review of the medical record revealed there was no weekly skin assessment documented on the "Reason for Assessment" form performed by the RN on Saturday, 10/15/11 for Patient #2 as per protocol.

Further review revealed there was a "Reason for Assessment Weekly" form that had the date, 10/15/11, written on the top of the page for Patient #2. The form was signed by the RN (S7) and dated 10/16/11.

In an interview on 01/03/12 at 9:18 a.m., S6RN verified she provided Patient #2 nursing care during her shift on 10/15/11. S6RN indicated the night shift performs the weekly skin assessment of the patients every Saturday as per protocol. S6RN denied performing the weekly skin assessment for Patient #2 during her shift on 10/15/11.

During an interview on 12/29/11 from 10:20 a.m. to 10:50 a.m., S7RN confirmed she provided nursing care to Patient #2 during her night shift on 10/15/11. S7RN indicated she did not perform the weekly skin assessment of Patient #2 as scheduled on Saturday, 10/15/11.

In the same interview on 01/03/12 at 10:30 a.m., the DON S2 confirmed there was no weekly Saturday skin assessment performed for Patient #2 dated 10/15/11 as per protocol.

3)
Patient #2
Review of the "Daily Skin Assessment Sheet" form section titled, "Instructions" read in part, "...When giving bath or conducting skin assessment, circle appropriate area that is affected. Identify area by checking the appropriate box. Upon completion of assessment, report any and all findings to the charge nurse...".

The "Daily Skin Assessment Sheet" dated 10/12/11 by the Mental Health Tech (MHT) for Patient #2 revealed there was no countersignature by the RN (S3). Further review of the "Daily Skin Assessment Sheet" dated 10/12/11 for Patient #2 revealed there were two diagrams noted on the form with a pictured diagram of a person's front and back side(s). Both persons on this form were left blank. Further the MHT documented there was "no finding" noted of the patient's (#2's) skin assessment performed during the new admit bath/shower on 10/12/11. There was no documentation of Patient #2's bruising to the right elbow and forearm; reddened excoriated area to the left upper buttock area; well-healed scars to the abdomen and/or two (2) scars to the back; two (2) open areas Stage II Pressure Wounds to the right buttocks area; and/or one (1) open area Stage II Pressure Wound to the left buttocks area as assessed by S2DON and S3RN during the initial nursing assessments of Patient #2 on 10/12/11.

Review of the "Daily Skin Assessment Sheet(s)" performed by the MHT(s) and countersigned by S7RN on 10/14/11, 10/15/11 and 10/16/11 revealed there was no documentation the patient (#2) had a Stage II to buttocks area and/or right heel bruise documented on the picture diagram of the patient's front and back view(s) by the MHT as per protocol.

The "Daily Skin Assessment Sheet" dated 10/17/11 was reviewed and revealed the patient (#2) she had "broken skin buttocks red /c several open areas" documented by the MHT(s) and countersigned by the RN S5. Further review revealed there was no documentation on the picture diagram of the patient's (#2's) back view of broken skin to the buttocks area. This section on the form was left blank. There was no documentation on the pictured diagram of the patient's (#2's) front and/or back views of bruising to the bilateral hands and forearms documented by the MHT on 10/17/11. This section on the form ("Daily Assessment Sheet") was left blank.

The "Daily Skin Assessment Sheet" of Patient #2 revealed she had "reddened skin buttocks red several open areas" was documented by the MHT with no countersignature by the RN (S4) on 10/18/11. Further review revealed there was no documentation on the pictured diagram of the patient's (#2's) reddened skin to the buttocks area with several open areas and/or bilateral bruising to the hands and forearms documented by the MHT as per protocol.

Review of the "Daily Skin Assessment Sheet" for 10/19/11 revealed there was no documented evidence the patient had "Stage II to buttocks" area and "bruising to the right heel" documented by the MHT and countersigned by the RN S7. There was no documentation on the pictured diagram of Patient #2 had "Stage II to buttocks" area and/or "bruising to the right heel" documented by the MHT.

The "Daily Skin Assessment Sheet" for 10/20/11 revealed the patient (#2) had a "Stage II to buttocks" documented by the MHT and countersigned by S7RN. Further review revealed there was no documented evidence the patient (#2) had "Stage II to buttocks" area and/or "bruising to the right heel" documented by the MHT on the pictured diagram of Patient #2's "Stage II to buttocks" area and/or "bruising to the right heel".

Review of the "Daily Skin Assessment Sheet" dated 10/21/11 revealed Patient #2 had "no new finding" documented by the MHT and countersigned by S5RN. Further review revealed there was no documentation of the patient's (#2's) "buttock red /c several open areas" documented by the MHT and S5RN on the pictured diagram on 10/21/11.

The "Daily Skin Assessment and Bath Sheet" dated 10/22/11 revealed the patient (#2) had no documented evidence of a blister to the left heel documented by the MHT and countersigned by S5RN.

Review of the "Daily Skin Assessment Sheet" dated 10/23/11 revealed there was no documentation on the pictured person diagram and/or on the form of what skin assessment was performed on Patient #2 during the bed/bath/shower by the MHT and countersigned by S5RN.

The "Daily Skin Assessment and Bath Sheet" dated 10/24/11 revealed there was no documentation Patient #2 had "Stage II to rt (right) buttock & (and) several tiny open areas to buttock and cheeks" and "rt heel bruising" documented by the MHT and countersigned by the RN S7.

Review of the "Daily Skin Assessment and Bath Sheet" dated 10/25/11 revealed the patient (#2) had "broken skin Stage II to rght (right) buttock & several tiny open areas to butt & cheek and rght (right) heel bruising" documented by the MHT and countersigned by the RN S7. Further review revealed there was no documented evidence on the picture

Based on record reviews and staff interviews, the nursing staff failed to develop and keep current a nursing care plan for the medical conditions, medication orders and/or physician orders for Patient #2 as evidenced by: 1) failing to have documented evidence the medication orders (Meloxicam, Macrobid, Docusate Sodium, Gabopentin (Neurontin), Furosemide, Glyburide, Metformin, Lantus, Omeprazole, Nystatin & Triamcimolone, Nystap, Multivitamin, Vitamin C, Juven, Zinc Sulfate) and/or the patient's medical conditions (osteoarthritis, pain, paralysis bilateral lower extremities (BLE) below waist, Insulin Dependent Diabetes Mellitus, wounds to buttocks areas, bruising to heels, urinary tract infection, constipation, hypertension, Gastroesophageal reflux disease) were developed, updated and/or revised on the patient's (#2's) treatment plan during her hospital stay from 10/12/11 through 10/27/11 for 1 of 5 sampled records reviewed (#2), and 2) failing to have documented evidence physician orders for accu checks every 12 hours from 10/12/11 to 10/27/11 and patient should not be up in wheelchair greater than three (3) hours without rest period and when patient is in the bed to be turned from side to side with no back laying from 10/16/11 to 10/27/11 for 1 of 5 sampled records reviewed. Findings:

Review of the "Physician's Order" dated/timed 10/12/11 at 5:40 p.m. (1740) revealed a list of medications for the patient (#2) upon admission into the hospital. Further review of the "Medication List" for Patient #2 revealed the following orders:
Meloxicam 7.5 mg (milligrams) oral every day- treatment for osteoarthritis,
Hydrocodone 10 mg/650 mg one (1) tablet oral four (4) times a day (QID)- treatment of pain,
Glyburide 2.5 mg one oral BID and Lantus solo star forty-six (46) units (U) subcutaneous (SQ) every (q) night (hs) treatment for IDDM,
Gabapentin (Neurontin) 600 mg oral 2 tablets oral three (3) times a day (TID)- treatment for diabetic neuropathy treatment,
Nystatin & (and) Triamcimolone per incontinent episode tap per episode (sic) and Nystap 100,000 unit to bottom apply as needed-treatment for wound to buttocks areas,
Macrobid 100 mg one (1) tablet oral two (2) times a day (BID) for 10 (ten) days-treatment for UTI,
Docusate Sodium 100 mg oral one tablet BID- treatment for constipation,
Furosemide 40 mg one tablet oral everyday- treatment for hypertension, and
Omeprazole 40 mg one tablet oral everyday-treatment for GERD.

Review of the "History and Physical" of the patient (#2) revealed the physician (S10MD) handwrote the patient's date of admission as 11/21/11 (sic). The patient's (#2's) hospital stay was from 10/12/11 through 10/27/11. Further review of the "History and Physical" form for Patient #2 revealed the physician S10MD signed the form on 10/13/11. S10MD assessed the patient as follows: "...Present Illness: Depression d/o...Past Medical History:...OA/DM/GERD/(R) leg pain chronic...wounds...DM...".

Review of the "Multidisciplinary Integrated Treatment Plan" dated 10/12/11 with a date met of 10/27/11 for Patient #2 read in part, "...Diagnosis: Axis I Depression...Discharge Criteria & (and) Long Term Goals...". Further review of the "Treatment Plan" revealed there was documentation of the physician's orders for the patient's medications (Meloxicam, Macrobid, Docusate Sodium, Gabopentin/Neurontin, Furosemide, Glyburide, Metformin, Lantus, Omeprazole, Nystatin & Triamcimolone, Nystap, Multivitamin, Vitamin C, Juven, Zinc Sulfate) and/or medical conditions (osteoarthritis, pain, paralysis bilateral lower extremities (BLE) below waist, IDDM, wounds to buttocks areas, bruising to heels, urinary tract infection, constipation, hypertension, and/or GERD) were developed, revised, and/or updated on the treatment plan for Patient #2 from 10/12/11 to 10/27/11. Further review revealed there was no documented evidence the accu checks every 12 hours ordered by the physician were developed, updated and/or revised on the treatment plan for Patient #2. There was no documented evidence of the physician's orders dated 10/16/11 for the "..patient should not be up in wheelchair greater than three (3) hours without rest period-when in bed turn side to side no back laying..." were developed, updated and/or revised to the treatment plan for Patient #2 from 10/12/11 through 10/27/11.

Review of the "Problem List" revealed Patient #2 had the following medical conditions as follows: Arthritis (OA), Pain, Paralysis (BLE) bilateral lower extremity below waist, Diabetes Mellitus (IDDM), Skin Breakdown, and UTI was initiated by the nursing staff on 10/12/11 and was documented as resolved by the staff on 10/27/11 and Constipation, Hypertension (HTN), and GERD was initiated by the nursing staff on 10/13/11 and documented as resolved by the staff on 10/27/11. Further review of the "Problem List" revealed there was no documented evidence the patient's (#2's) medical conditions of osteoarthritis (OA), pain, paralysis bilateral lower extremities (BLE) below waist, IDDM, wounds to buttocks areas, bruising to heels, urinary tract infection (UTI), constipation, hypertension (HTN) and/or GERD were developed, updated, and/or revised with short term goals, long term goals, discharge criteria and/or interventions implemented on the treatment plan for Patient #2 during her hospitalization from 10/12/11 to 10/27/11. There was no documentation the treatment plan was developed, updated/revised with the physician's orders for the patient's medications (Meloxicam, Macrobid, Docusate Sodium, Gabopentin/Neurontin, Furosemide, Glyburide, Metformin, Lantus, Omeprazole, Nystatin & Triamcimolone, Nystap, Multivitamin, Vitamin C, Juven, Zinc Sulfate) from 10/12/11 through 10/27/11. Further review revealed there was no documented evidence the physician's orders for accu checks every twelve (12) hours for Patient #2's IDDM was developed, revised/updated on the treatment plan during her stay from 10/12/11 to 10/27/11. There was no documented evidence the physician's orders dated 10/16/11 with no time that the physician wrote the order for the "...patient to not be up in wheelchair greater than three (3) hours without rest period-when in bed turn side to side no back laying..." were developed, revised and/or updated on the treatment plan for Patient #2.

Review of the "Nursing Initial Skin Assessment" dated 10/12/11 with no time documented that the assessment was performed by the Director of Nursing (DON) S2 revealed Patient #2 had a "right (R) heel Pressure Wound cannot stage, well-healed scars to the abdomen area and two (2) areas to the back, reddened excoriated (rash-like) above the left buttocks area, bruise to the right forearm and elbow area(s), and two (2) open areas Stage II Pressure Wounds on the right buttocks area and one (1) "open area Stage II Pressure Wound" to the left buttocks area.

The "Physician's Orders" dated/timed 10/13/11 at 9:35 a.m. (0935) for Patient #2 were reviewed. Further review of the "Physician's Orders" revealed the patient's Glyburide 2.5mg one tablet medication order was changed to Glyburide 5mg a half (1/2) tablet twice (BID) daily and Metformin 500mg one tablet twice (BID) daily for Patient #2.

Review of the "Physician's Orders" dated 10/13/11 with no time documented that the physician wrote the order read in part, "...2 Accu checks every 12 hours (q12) with (c) sliding scale (S/S)..." for Patient #2.

The "Physician's Orders" dated 10/14/11 for Patient #2 were reviewed. Further review of the "Physician's Orders" dated 10/14/11 revealed there was no time documented that the physician wrote an order to decrease the Neurontin (Gabapentin) 600 mg to one tablet oral TID.

Review of the "24 Hour Assessment/Reassessment" form section titled, "Integumentary" dated 10/15/11 and 10/16/11 revealed the nursing staff (S6RN, S7RN) assessed the patient (#2) with "Stage II to buttocks" area and "bruising to the right heel".

Review of the "Physician's Orders" dated 10/16/11 for Patient #2 revealed there was no time documented that the physician wrote an order to decrease Docusate to daily and increase the Lantus medication to forty-eight (48) units SQ every night (QHS) for Patient #2. There was another order written on 10/16/11 that read as follows: "...Patient should not be up in wheelchair greater than three (3) hours without rest period-when in bed turn side to side no back laying...".

Review of the "24 Hour Assessment/Reassessment" section(s) titled, "Integumentary" dated 10/16/11 revealed S6RN assessed Patient #2 with a "Stage II to buttocks" and "bruising to right heel".

Review of the "Reason for Assessment Weekly" form that had the date, 10/15/11, written on the top of the page. The form was signed by the nurse, S7RN on 10/16/11. Further review revealed the patient (#2) had "Buttocks red /c several open areas noted...Bruising to bilat hands and forearms, posterior right heel purple area cannot stage ...".

The "Physician's Orders" dated/timed 10/17/11 at 4:44 p.m. (1644) for Patient #2 were reviewed. Further review of the "Physician's Orders" dated/timed 10/17/11 at 4:44 p.m. for the patient (#2) read in part, "...1 Multivitamin one (i) oral (PO) daily(,) 2 Vit (vitamin) C 500mg PO BID(,) 3 Zinc Sulfate 220mg PO daily(,) 4 Juven i packet mixed /x 6 oz (ounces) H2O (water) BID...".

Review of the "24 Hour Assessment/Reassessment" section(s) titled, "Integumentary" dated 10/17/11 revealed the RN, S4 assessed Patient #2 with "buttocks red /c (with) several open areas" and "bruising bil (bilateral) hands and FAs (forearms).

Review of the "24 Hour Assessment/Reassessment" form "Integumentary" section dated 10/18/11 revealed the nurse, S4RN assessed the patient (#2) with "buttock red /c several open areas" during her shift. Further review revealed there was no documented evidence of bruising to the patient's (#2's) bilateral hands and forearms as documented by the nurse (S4RN) during her assessment of the patient on 10/18/11. S4RN (the same nurse) assessed the patient (#2) the day before (10/17/11) with "bruising to the bilateral hands and forearms".

Review of the "24 Hour Assessment/Reassessment" section(s) titled, "Integumentary" dated 10/19/11 and 10/20/11 revealed the nursing staff (S6RN, S7RN) assessed the patient (#2) with "Stage II to buttocks open areas" and "bruising to the right heel".

The "24 Hour Assessment/Reassessment" section titled, "Integumentary" dated 10/21/11 revealed the nurse, S4RN assessed the patient (#2) with "buttock red /c several open areas" at 6:45 a.m. (0645).

Review of the "Physician's Orders" dated 10/22/11 revealed there was no time documented that the physician wrote the order to increase the Lantus medication to fifty (50) units (U) SQ daily and skin prep to heels everyday (QD)-offload when in bed for Patient #2.

Review of the "24 Hour Assessment/Reassessment" dated 10/22/11 revealed the patient (#2) was assessed with "buttock red /c several open areas" and "blister (L) heel" by the nurse, S4RN at 8:00 a.m. (0800).

Review of the "Reason for Assessment" sheet with no documentation of the reason the assessment for Patient #2 was performed by the nurse, S5RN on 10/22/11. Further review of the "Assessment" form for Patient #2 was assessed with a "Stage II (R) buttock(,) small scattered lesions coccyx(,) (L) ischial wound(,) (L) heel /c 2 boggy areas" by S5RN on 10/22/11.

Review of the "24 Hour Assessment/Reassessment" dated 10/23/11 revealed Patient #2 had "buttock red /c several open areas" and "blister (L) heel" documented by the nurse, S4RN.

Review of the "24 Hour Assessment/Reassessment" dated 10/24/11 revealed Patient #2 had a "Stage II to rt (right) buttock & (and) several tiny open areas to buttock and cheeks" and "rt heel bruising" documented by S4RN, S6RN, and S7RN.

Review of the "24 Hour Assessment/Reassessment" dated 10/25/11 revealed Patient #2 was assessed with a "Stage II to rt (right) buttocks & (and) several tiny open areas to buttock and cheeks" and "right heel bruising" by the nurse, S6RN.

Review of the "24 Hour Assessment/Reassessment" dated 10/26/11 revealed Patient #2 had "buttock red /c several open areas" and "blister (L) heel" documented by the nurse, S4RN.

Review of the "Reason for Assessment: Discharge" form dated 10/27/11 with no time documented that the assessment was performed by S4RN read in part, "resolving Stage II to buttocks area(s)" and "blisters on bilateral heels".

Review of the medical record revealed there was no documentation the treatment plan for Patient #2 was developed, updated/revised with the physician's orders for the patient's medications (Meloxicam, Macrobid, Docusate Sodium, Gabopentin/Neurontin, Furosemide, Glyburide, Metformin, Lantus, Omeprazole, Nystatin & Triamcimolone, Nystap, Multivitamin, Juven, Vitamin C, Zinc Sulfate) and/or medical conditions (osteoarthritis, pain, paralysis bilateral lower extremities (BLE) below waist, Insulin Dependent Diabetes Mellitus, wounds to buttocks areas, bruising to heels, urinary tract infection, constipation, hypertension, and/or Gastroesophageal reflux disease for Patient #2 during her hospital stay from 10/12/11 through 10/27/11. Further there was no documented evidence in the medical record of the physician's orders for accu checks every twelve (12) hours for Patient #2's IDDM was developed, revised, and/or updated on the treatment plan. There was no documentation of the physician's orders dated 10/16/11 for the "...patient should not be up in wheelchair greater than three (3) hours without rest period-when in bed turn side to side no back laying..." was developed, revised, and/or updated on Patient #2's treatment plan.

In telephone interviews conducted on 01/20/12 at 3:15pm and on 02/09/12 at 11:45am, S2DON indicated the treatment plan includes both the psychiatric and medical conditions of the patients. S2DON verified there was no documentation of Patient #2's wounds and/or bruising to heels during her hospital stay with interventions implemented. S2DON indicated there was no documented evidence on the "Multi-Disciplinary Treatment Plan" and/or "Problem List" that included Patient #2's wounds to buttocks and/or bruising to her heels during her hospital stay from 10/12/11 through 10/27/11 as per protocol. S2DON verified there was no documentation on the treatment plan of Patient #2's medical conditions of Insulin Dependent Diabetes Mellitus (IDDM), osteoarthritis (OA), pain, paralysis bilateral lower extremities (BLE) below waist, wounds to buttucks, bruising to heels, urinary tract infection (UTI), constipation, and/or hypertension (HTN) with short/long term goals and interventions implemented for the patient's medical conditions as per protocol. S2DON denied knowledge the Treatment Plan did not include Patient #2's medical conditions of Insulin Dependent Diabetes Mellitus (IDDM), osteoarthritis (OA), wounds to buttocks, bruising to heels, pain, paralysis bilateral lower extremities (BLE) below waist, or urinary tract infection (UTI), constipation, and/or hypertension (HTN) with interventions implemented for these conditions. S2DON further indicated all medical conditions are identified by nursing staff on the "Problem List" form. S2DON reported there were no interventions implemented by the nurses documented on the "Problem List" form and/or in the 24Hour Reassessment/Assessment" forms for Patient #2's medical conditions (Insulin Dependent Diabetes Mellitus (IDDM), osteoarthritis (OA), pain, paralysis bilateral lower extremities (BLE) below waist, or urinary tract infection (UTI), constipation, and/or hypertension (HTN). S2DON further reported there were no interventions implemented on the "Multi-Disciplinary Treatment Plan" for Patient #2's medical conditions of Insulin Dependent Diabetes Mellitus (IDDM), osteoarthritis (OA), pain, paralysis bilateral lower extremities (BLE) below waist, wound to buttocks area, bruising to heels, urinary tract infection (UTI), constipation, and/or hypertension (HTN). S2DON indicated there were no medical conditions (Insulin Dependent Diabetes Mellitus (IDDM), osteoarthritis (OA), pain, paralysis bilateral lower extremities (BLE) below waist, or urinary tract infection (UTI), constipation, wounds to buttocks area, bruising to heels, and/or hypertension (HTN) for Patient #2 noted on the "Multidisciplinary Treatment Plan" initiated by nursing staff on 10/12/11 and documented as resolved by the staff on 10/27/11. S2DON stated the patient's (#2's) medical conditions were identified by the nursing staff on the "Problem List" form. S2DON reported there were no interventions noted on the "Problem List" for Patient #2's medical conditions. S2DON indicated the treatment plan had discharge criteria and long term goals with interventions implemented for Patient #2's diagnosis of "Depression". S2DON disagreed that Patient #2's medical conditions on the treatment plan did not have discharge criteria, long term goals and interventions implemented during her stay at the hospital. S2DON agreed the treatment plan did not include short term goals regarding Patient #2's medical conditions. The DON S2 reported there was a new policy implemented regarding treatment plan since the last survey (exited on 01/03/12) and all employees will be in-serviced regarding the new treatment plan tomorrow (02/10/12). The surveyor requested all information regarding the treatment plan and in-servicing faxed to the office and the office fax number was supplied to the DON at this time.

The policy titled, "TX-Gen-02: Treatment Planning; Integrated/Multidisciplinary", Date adopted of January 2007, with no revised and/or reviewed dates, faxed on 02/09/12 at 2:53pm indicated the multi-disciplinary treatment team shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. The purpose is to document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient's treatment to promote positive patients outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. The admitting physician provides the prescribed treatment modalities for the initial plan of care. The admitting registered nurse formulates the treatment plan based on the physician's orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, and family/significant other information within 8 hours of admit or sooner if patient's needs warrants immediate action. The Registered Nurse implements treatment interventions for safety and stabilization of the patient. This preliminary plan of care addresses presenting needs of the patient. The Registered Nurse initiates an individualized treatment problem/nursing diagnosis list as identified in the assessment of the patient. The nurse revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders. All physicians' orders are included in the Treatment Plan. The nurse revises the plan based on changes in condition and physician's orders received. All physicians' orders will be added to the Treatment Order. The Multi-Disciplinary Team Members will document on weekly Treatment Plan Summary the patient's progress toward treatment planning goals and objectives and any obstacles that prevent progress. A priority of the patient's needs is developed and updated to indicate the prospective treatment focus including acute and sub-acute problems and interventions. The Multi-Disciplinary Team will document clinical justification for determents of problems with clinical rationale. These deferred problems need to be addressed post-discharge will be included in the discharge planning process. The Multi-Disciplinary Team will document the patient's coping limitations and strengths and devises interventions which utilize strengths as well as any discharge/continuing stay criteria. The Multi-Disciplinary Team assesses, develops, documents, and/or reviews the Continuing Care Plan within 48 hours of discharge with patient (and patient's family if indicated) and documents the patient's response to post treatment plans. All internal and external care treatment and services are coordinated by the Multi-Disciplinary Team. All care treatment and services are reviewed in treatment staffing.