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Based on record review and interview the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan based on assessing patient's needs and developing appropriate nursing interventions in response to those needs for one (1) of five sampled patients (#2).

Findings:

Record #2 reflected that the patient was admitted on 06/01/2010 and the initial assessment by nursing included the documentation of skin as normal. The patient 's risk of developing pressure ulcers (Braden Scale) documented on 06/01/10 did not reflect any issues. On 06/02/10 the record reflected activity as severely limited and nutrition as probably inadequate. On 06/03/10 the record reflected activity as bedfast, mobility as slightly limited, nutrition as adequate, and friction as potential problem. On 06/04/10 the record reflected activity as walks occasionally, mobility as slightly limited, and nutrition as adequate. On 06/05/10 the record reflected activity as chair fast, mobility as very limited, nutrition as adequate and friction as potential problem.

The nursing notes from admission through 06/03/10 at 12:03 p.m. failed to document any assessment of the patient 's coccyx area. On 06/03/10 at 12:03 p.m. the nursing notes reflected that coccyx was reddened and that barrier cream was applied, and that at 3:18 p.m. an air mattress was placed on the bed. The record failed to reflect another assessment of the coccyx area until 06/07/10 at 3:44 a.m. when the nursing notes reflected an open pressure area approximately 4 centimeters (cm) x 4 cm on the coccyx with deep purple discoloration of the surrounding tissues. The notes also reflected that the area was cleansed and a DuoDerm dressing was applied.

Interview with the vice president of nursing and the director of medical surgical nursing on 07/21/2010 at 12:15 p.m. confirmed the standard of care was to assess patients' skin integrity every shift and to document changes from normal. She also confirmed that patients with abnormal assessments on the Braden Scale and with identified changes in skin integrity should be assessed at least every shift with documentation of the developing pressure area.

Interview with vice president of nursing and director of risk and compliance on 07/21/2010 at 1:15 p.m. confirmed records were accurate.

Based on record review and interview the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan based on assessing patient's needs and developing appropriate nursing interventions in response to those needs for one (1) of five sampled patients (#2).

Findings:

Record #2 reflected that the patient was admitted on 06/01/2010 and the initial assessment by nursing included the documentation of skin as normal. The patient 's risk of developing pressure ulcers (Braden Scale) documented on 06/01/10 did not reflect any issues. On 06/02/10 the record reflected activity as severely limited and nutrition as probably inadequate. On 06/03/10 the record reflected activity as bedfast, mobility as slightly limited, nutrition as adequate, and friction as potential problem. On 06/04/10 the record reflected activity as walks occasionally, mobility as slightly limited, and nutrition as adequate. On 06/05/10 the record reflected activity as chair fast, mobility as very limited, nutrition as adequate and friction as potential problem.

The nursing notes from admission through 06/03/10 at 12:03 p.m. failed to document any assessment of the patient 's coccyx area. On 06/03/10 at 12:03 p.m. the nursing notes reflected that coccyx was reddened and that barrier cream was applied, and that at 3:18 p.m. an air mattress was placed on the bed. The record failed to reflect another assessment of the coccyx area until 06/07/10 at 3:44 a.m. when the nursing notes reflected an open pressure area approximately 4 centimeters (cm) x 4 cm on the coccyx with deep purple discoloration of the surrounding tissues. The notes also reflected that the area was cleansed and a DuoDerm dressing was applied.

Interview with the vice president of nursing and the director of medical surgical nursing on 07/21/2010 at 12:15 p.m. confirmed the standard of care was to assess patients' skin integrity every shift and to document changes from normal. She also confirmed that patients with abnormal assessments on the Braden Scale and with identified changes in skin integrity should be assessed at least every shift with documentation of the developing pressure area.

Interview with vice president of nursing and director of risk and compliance on 07/21/2010 at 1:15 p.m. confirmed records were accurate.