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Based on observation, interview and record review, the facility failed to ensure that the staff followed the facility policy for wound care and treatment, for one current patient (#17) of two observed and two discharged patients (#16, #18) of six reviewed. These failures had the potential to deny all patients in the facility pressure ulcer (injury to skin and underlying tissue by staying in one position too long) and wound care treatment. The facility census was 13.

Findings included:

1. Record review of the facility's policy titled, "Pressure Ulcer/Wound Protocol, Assessment and Treatment", dated 12/2015, showed patient's skin needed to be assessed within four hours of admission and documented at 12-hour intervals. The facility policy expected a skin risk assessment with a Braden score (a universal scale used to assess patient's level of risk for development of pressure ulcers, staging, measurement, treatment and documentation of all pressure ulcers.) The policy directed staff to stage (a method of identifying the level of deterioration and/or depth of a pressure sore) and measure the size of a pressure sore in centimeters (cm, one inch equals approximately 2.5 cm) to include length by width, by depth. Staff were to take pictures of a pressure sore on admission, when identified, monthly, upon discharge and with significant deterioration. If the patient had a Stage II (partial thickness skin loss, usually superficial and presents as a blister, abrasion or shallow crater) or greater wound, the dietitian would consult for supplementation recommendations.

2. Record review of current Patient #17's Emergency Department record, dated 04/12/16, showed the patient had a reddened skin rash in the left groin fold.

Record review of Patient #17's History and Physical (H&P) dated 04/12/16, showed the patient was admitted with diagnoses of diabetes ((a chronic condition that effects the way the body processes blood sugar and can cause poor circulation and poor wound healing ability), poor intake (can contribute to poor healing ability), and urinary incontinence (can cause skin breakdown). The H&P failed to identify any skin rashes or redness.

Record review of the patient's admission nursing assessment dated 04/12/16, showed the patient had a generalized pink tailbone (sacrum/coccyx) with a rash. Staff failed to measure or describe the size of this pink/reddened area.

3. Observation in the patient's room, and concurrent interview on 04/13/16 at 9:11 AM, showed the following:
- Patient #17 stated that she had been sick, in her home, for about four weeks. During this time, she sat in a recliner chair, with very little mobility (this can create skin breakdown). She stated that she had noticed some blood on toilet tissue recently, after wiping, but did not know exactly why.
- Patient #17 had a large area of redness approximately 20 cm by ten cm, that started above the crack of the buttocks and extended clear down to the upper/inner thighs and groin.
- There was an elongated open area within this reddened area, that was approximately 2.0 cm long by 1.0 cm wide.
- Staff J, Registered Nurse (RN), stated that the open area had not been there the day before, on admission). Staff J described this open area as being a Stage I (non-blancheable, skin color does not turn white when touched, redness of intact skin), rather than a Stage II.

Record review of a physician's progress note dated 04/13/16 showed the patient had a red peri-rectal (surrounding the rectum) area with a small scratch to the right peri-rectal area.

Record review of physician's orders showed an order for a barrier cream dated 04/13/16, after the open area developed. Staff failed to obtain an order to treat the reddened rash area on admission.

4. Record review of discharged Patient #18's H&P dated 01/24/16, showed the patient was admitted on that date with a Stage IV (full thickness skin loss with extensive destruction, tunneling, which is a passage way of tissue destruction under the skin surface that has an opening at the skin level, tissue death or damage to muscle, bone, or supporting structures) pressure sore on the tailbone (coccyx) area.

Record review of the nursing wound assessment dated 01/24/16, showed the patient had a pressure sore with tunneling on the coccyx. Review of further nursing wound assessments (through 01/27/16) showed staff failed to stage the pressure sore.

Record review of physician's progress notes from 01/24-26/16 showed the patient's Albumin level (a protein in the blood in which a low level can be indicative of poor wound healing ability) was low at 2.9 gm/dL (grams per deciliter-normal is 3.5-5.5).

Record review of nutrition notes dated 01/26/16 and 01/27/16, showed no evidence the dietitian was aware of the patient's Stage IV pressure sore (so they could determine additional protein needs for wound healing). Staff failed to consult the dietitian.

5. Record review of discharged Patient #16's H&P dated 02/15/16 showed the patient was admitted with a diagnosis of sepsis (infection where bacteria infects the bloodstream), pneumonia (lung infection) and diabetes and end stage renal failure causing poor wound healing ability. No skin issues noted.

Record review of Patient #16's nursing documentation of Braden scores showed a score of 15 (low risk), dated 02/15/16, 02/16/16 and 02/20/16; and a score of 14 (medium risk), dated 02/16/16 through 02/19/16.

Record review of Patient #16's nursing assessment dated 02/15/16 through 02/20/16 showed patient had a urinary catheter (tube placed in the body to drain and collect urine from the bladder) in place and on 02/16/16, 02/17/16 and 02/18/16 showed patient was incontinent of stool, which could cause poor wound healing ability.

Record review of Patient #16's nursing admission assessment dated 02/15/16 at 9:00 PM, showed left anterior foot wound open to air with no description or measurements.

Record review of Patient #16's nursing assessments dated 02/16/16 through 02/20/16 showed the following wounds:
-02/16/16 at 9:38 AM showed left anterior foot wound with no description or measurement;
-02/16/16 at 9:00 PM, 02/17/16 at 8:00 AM and 02/17/16 at 9:00 PM, showed left buttock pressure ulcer and left anterior foot wounds, present on admission, pictures taken and open to air with no description, staging or measurements;
-02/18/16 at 8:00 AM, 02/18/16 at 9:00 PM, and 02/19/16 at 9:50 PM showed penis maceration (the breakdown of skin from prolonged exposure to moisture), left buttock pressure ulcer and left anterior foot wounds, present on admission, open to air and no measurements;
-02/20/16 at 8:30 AM showed left anterior foot stage IV wound with dressing but no measurement.

Record review of Patient #16's discharge orders dated 02/20/16 at 5:18 PM showed an anatomical diagram indicating a Stage IV wound on the buttock, blister on the left foot and penis redness and edema with no measurements.

Record review of Patient #16's medical record showed that Staff F, Hospitalist (a medical professional mainly caring for hospitalized patients), charted that patient had no skin issues between 02/16/16 and 02/20/16.

Record review of Patient #16's phsician's orders showed that Staff F, Hospitalist, ordered a wound care consult on 02/18/16 at 7:13 PM with Staff L, wound care specialist, to assess Patient#16's left buttock pressure ulcer and maceration to the penis. Documentation of Staff L, showed assessment of patient's left buttock pressure ulcer, but no documentation of macerated penis.

During an interview on 04/12/16 at 2:32 PM, Staff D, RN, Director of Medical Surgical floor, stated that she expected nurses to perform and document skin assessments every 12 hours. She expected them to describe, measure and stage all pressure ulcers.

During an interview on 04/12/16 at 3:10 PM, Staff F, Hospitalist, stated that if he were not alerted by nursing he would not have assessed patient's skin every day. Staff F stated that his priority was cardiac and other body systems. He stated that his focus was not on the patient's skin.

During an interview on 04/13/16 at 10:13 AM, Staff B, Intensive Care Nurse Manager, stated that she expected nurses to complete a full assessment every shift. Staff B stated that she expected nurses to photograph, stage, and measure wounds, then notify physician if there is any deviation from normal.

During an interview on 04/13/16 at 2:04 PM, Staff E, Chief Nursing Officer, stated that the staff were inconsistent with measuring and staging. He stated that it was a disconnect of communication between the physicians and the nurses.


















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Based on observation, interview, record review, and policy review the facility failed to develop and/or update plans of care for two current patient's (#11, #17), and two discharged patient's (#16, #18), of eight reviewed. These failures had the potential to affect all patients by having unidentified patient needs which could lead to poor patient outcomes. The facility census was 13.

Findings include:

1. Record review of the facility's policy titled, "Plan of Care," dated 05/2015, showed the following:
- The patient's plan of care shall reflect identified problems, goals and interventions.
- Disciplines involved in the care will assist in the developing, implementing, and updating the patient's plan of care as necessary.
- The patient's plan of care will be individualized and appropriate to the patient's needs, limitations and goals.

2. Record review of current Patient #11's History and Physical (H&P) dated 04/08/16, showed he was admitted on that date with a diagnosis of a left foot wound with infection. This foot wound required an incision and drainage procedure, whirlpools, and frequent dressing changes. The patient was taking antibiotics and pain medications for this foot wound.

Record review of the patient's care plan on 04/11/16, dated 04/08/16, showed staff failed to identify/address the patient's left foot wound and/or infection.

3. Record review of current Patient #17's Emergency Department record, dated 04/12/16, showed the patient had a reddened skin rash in the left groin fold.

Record review of the patient's admission nursing assessment dated 04/12/16, showed the patient had a generalized pink tailbone (sacrum/coccyx) with a rash.

4. Observation in the patient's room, and concurrent interview on 04/13/16 at 9:11 AM, showed Patient #17 had a large area of redness approximately 20 centimeters (cm, one inch equals approximately 2.5 cm) ) by ten cm, that started above the crack of the buttocks and extended clear down to the upper/inner thighs and groin. There was an elongated open area within this reddened area, that was approximately 2.0 cm long by 1.0 cm wide.

Record review of the patient's plan of care dated 04/13/16, showed staff failed to identify/address the patient's reddened buttocks and/or open area.

5. Record review of discharged Patient #16's H&P dated 02/15/16, showed that the patient was admitted with a diagnosis of sepsis (infection where bacteria infects the bloodstream), pneumonia (lung infection), diabetes (a chronic condition that effects the way the body processes blood sugar), end stage renal failure, left buttock pressure ulcer (injury to skin and underlying tissue by staying in one position too long) and left anterior foot wound.
Record review of Patient #16's care plans dated 02/15/16 through 02/20/16, showed that staff failed to identify/address any skin issues.

Record review of Patient #16's nursing assessments dated 02/16/16 through 02/20/16 showed the following wounds:
-02/16/16 at 9:38 AM showed left anterior foot wound with no description or measurement;
-02/16/16 at 9:00 PM, 02/17/16 at 8:00 AM and 02/17/16 at 9:00 PM, showed left buttock pressure ulcer and left anterior foot wounds, present on admission, pictures taken and open to air with no description, staging or measurements;
-02/18/16 at 8:00 AM, 02/18/16 at 9:00 PM, and 02/19/16 at 9:50 PM showed penis maceration (the breakdown of skin from prolonged exposure to moisture), left buttock pressure ulcer and left anterior foot wounds, present on admission, open to air and no measurements;
-02/20/16 at 8:30 AM showed left anterior foot stage IV wound with dressing but no measurement.

6. Record review of discharged Patient #18's H&P dated 01/24/16, showed the patient was admitted on that date with a Stage IV (the most serious stage in terms of treatment and wound healing, and may feature extensive loss or damage to tissue, muscle and bones) pressure ulcer on the tailbone area.

Record review of the nursing admission assessment dated 01/24/16, showed the patient had a pressure sore with tunneling (wounds that have developed channels through tissue or muscle).

Record review of the patient's plan of care dated 01/24/16, showed staff failed to identify/address the patient's Stage IV pressure ulcer.

During an interview on 04/13/16 at 10:45 AM, Staff B, Intensive Care Manager, stated that she expected nurses to assess and update care plans every 12 hours.

During an interview on 04/12/16 at 3:45 PM, Staff D, Director of Medical Surgical Floor, stated that she expected nurses to assess wounds and update care plans every 12 hours.











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