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Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure nursing staff developed a nursing care plan for one of ten sampled patients (Patient #1). Patient #1 was admitted on 06/29/12 with no evidence of skin breakdown. The facility discharged the patient on 07/24/12 with pressure sores to the coccyx (left buttock), right hip, right heel, and left heel. Documentation revealed staff failed to develop a plan of care related to skin integrity until 07/23/12, eight days after the patient had been assessed to be at risk for the development of pressure sores and one day prior to discharge.

The findings include:

A review of the facility policy, "Nursing Care Plans," revised February 2012, revealed each patient was required to have an individualized plan of care based on his/her needs and problems. The plan of care was to be initiated by the registered professional nurse completing the admission assessment. The plan was to be evaluated and revised as indicated by the patient's response.

A review of Patient #1's medical record revealed the patient was admitted on 06/29/12, with diagnoses to include Schizoaffective Disorder, Mood Disorder, and Dementia with Alzheimer's. A review of a skin assessment completed by facility staff on 06/29/12, the day of admission, revealed there were no open or red areas on Patient #1's body. A review of a Braden Scale (a standardized scale used to identify a patient's risk for the development of pressure sores) assessment completed on 06/29/12 revealed Patient #1's score was 20, which indicated the patient was not at risk for the development of pressure sores. A review of a Braden Scale assessment completed by facility staff on 07/15/12, 16 days after the assessment completed on 06/29/12, revealed Patient #1's score was 15, and the assessment indicated the patient was at mild risk for the development of pressure sores. Three days later, on 07/18/12, facility staff assessed Patient #1 to have a Braden Scale score of 13, and indicated Patient #1 was at moderate risk for the development of pressure sores. However, a review of Patient #1's plan of care revealed even after the patient had been assessed to be at risk for the development of pressure sores facility staff failed to identify the patient to be at risk for the development of pressure sores and had not developed a skin integrity care plan to establish interventions to prevent the development of pressure sores. A review of a skin assessment completed by facility staff on 07/18/12 revealed Patient #1 was assessed to have blisters on both the right and left heels. A review of nursing notes dated 07/19/12 also revealed Patient #1 had a pressure sore to the right and left heel which appeared to be blisters and the physician was notified. Documentation revealed the physician requested for staff to "float" the patient's heels to relieve pressure. Further review of Patient #1's medical record revealed on 07/20/12 facility staff identified a Stage II pressure sore to the coccyx (left buttock). A review of physician's orders on 07/23/12, one day prior to discharge, revealed a dietary consultation was requested due to the development of the three pressure sores. The physician also requested staff to turn the patient every two hours, to provide wound care to the coccyx area, an air mattress to be placed on the patient's bed, and for heel protectors to be placed on both of Patient #1's heels. A review of nursing notes and a skin assessment dated 07/24/12 revealed Patient #1 was discharged on 07/24/12 with a Stage II pressure sore which measured 3 centimeters (cm) by 3 cm on the left buttock; a reddened area on the right buttock; a pressure sore on the right hip which was covered with a dressing; a pressure sore on the left heel which measured 5 cm by 6 cm and was described as purplish/red; and a pressure sore on the right heel which measured 8 cm by 5 cm. Further review of Patient #1's medical record revealed facility staff failed to develop a plan of care related to the Patient's potential/actual impaired skin integrity until 07/23/12, five days after the identification of the patient's first pressure sore, and one day prior to discharge.

Interview on 09/05/12 at 12:52 PM, with Registered Nurse (RN) #1 revealed Patient #1 was noncompliant with care. RN #1 stated facility staff assisted the patient with turning and repositioning every two hours and staff had provided the patient with heel protectors prior to 07/19/12 when the pressure sores were identified on the heels. RN #1 was not aware of when the heel protectors were first applied to the patient but the RN stated the patient would turn her/himself back over and remove the heel protectors. Further interview with RN #1 on 09/06/12 at 2:30 PM, revealed she did not develop a plan of care after identification of the pressure sores on the heels on 07/19/12, and since she had identified the problem she would have been responsible to develop a plan of care. RN #1 stated she "didn't do it," "had a bad day, just forgot."

Interview with Nursing Assistant (NA) #2 on 09/05/12 at 1:58 PM, revealed facility staff did attempt to reposition Patient #1 by placing a pillow behind the back and attempted to place heel protectors on the patient's feet. However, NA #2 stated the patient would remove the pillow and throw it on the floor and would also remove the heel protectors by moving around in bed.

Interview with the Nurse Manager of the unit on 09/06/12 at 4:00 PM, revealed it was the responsibility of the nurse who identified a problem with a patient to develop a plan of care after the initial admission plan of care had been developed. The Nurse Manager further stated a plan of care would not be developed for skin breakdown or pressure sore risk until a pressure sore had been identified on a patient.

Interview with the Director of Nursing Operations on 09/06/12 at 4:15 PM, revealed it was the responsibility of the nurse who identified a new problem with a patient to develop the plan of care for that problem. The Director of Nursing Operations stated a plan of care should have been developed prior to the pressure sores which were identified on 07/19/12. She further stated she did not have an explanation for why a plan of care had not been developed for Patient #1 prior to 07/19/12.