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Based on policy review, clinical record review and staff interviews the facility failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) F.S. for 5 of 10 sampled patients (Patient #1, #2, #4, #5 and #6) as evidenced by failure to accurately assessed skin conditions and wounds; failure to follow physician orders for wound care and Failure to reassess pain as specified in the facility policies and procedures for 1 of 10 sampled patients (Patient #5).


The findings include:


Facility policy titled "ssessment and Reassessment Plan" last revised 05/2014 documents, at the time of admission the initial assessment is the responsibility of the Registered Nurse. The information gathering includes skin integumentary/Integrity/Ulcer risk assessment. Patient assessment/reassessment documented in the CPCS by a nurse in the inpatient areas will compare the patient physical findings to defined parameters. If the physical findings match the defined parameters for the body system, the nurse will chart "Y" to query WDP. If any of the physical findings within the system is outside of the defined parameters, the clinician will document ONLY the physical findings outside the defined parameters.

Facility policy Surgical Wound Dressing documents Surgical wound care dressing changes will be performed at least daily or as indicated by the physician's order. Documentation of wound assessment will include the following: wound site, dressing type, dressing status (CHANGED), wound type, wound condition, measurements, color, drainage and any additional wound comments.

Facility policy Wound Management: Wound Healing by Secondary Intention documents The purpose is to provide a standard of care for the management of wounds healing by secondary intention and to promote healing and reduce further injury to tissue. Wound assessments and Documentation:
1. Documentation in CPCS of complete wound assessment, which requires removal of the dressing, will be done on admission and at least weekly thereafter. A complete assessment is done when any of the following conditions are present:
a. Dressing change
b. When the integrity of the dressing is compromised
c. When the secondary dressing becomes wet.

2. Complete wound assessment includes the following descriptors: Location, Dressing type, Wound type, Wound color, length, width, depth, documentation of wound location and status of dressings will be documented each shift assessment when a complete wound assessment is not completed and dressings are to be removed only for the purpose of changing the dressing and not solely for assessment documentation.


(1) Electronic clinical record review, conducted on 07/30/14 while accompanied by the Clinical Coordinator, revealed the following:

Patient #1 was admitted to the facility on 07/29/14 with a pressure wound to the hip/buttocks area as documented on the initial nursing assessment.
The Nursing shift assessment dated 07/29/14 at 8 PM does not contain evidence of an accurate skin assessment per policy, and documentation of the wound identified on admission.

(2) Patient #2 was admitted to the facility on 07/17/14 with two graft wounds, one to the left lower leg and one donor site wound to the left thigh. Review of random nursing shift assessments for Patient #2 failed to provide evidence the graft and donor sites were included and documented as part of the skin assessments: on 07/18/14 (AM); 07/19/14 (AM and PM); 07/20/14 (AM and PM); 07/21/14 (AM); 07/22/14 (AM); 07/23/14 (AM); 07/28/14 (AM) and 07/29/14 (PM).

(3) Patient #4 was admitted to the facility on 07/08/14. Physician Order dated 07/21/14 documents "wound care consult." Wound care consult dated 07/22/14 documents the patient developed an open area to the sacrum measuring 3.5 cm in length by 4 cm in width. The wound care recommendations document gently cleanse and pat dry, apply small amount of Remedy Z guard to the peeling skin to the sacrum and cover with border dressing every three days and as needed."
Review of Nursing shift Assessments dated 07/21/14, 07/22/14, 07/23/14 and 07/24/14 failed to yield evidence of the wound assessment of the sacrum. The wound was completely omitted from all the shift documented assessments.

(4) Patient #6 was admitted to the facility on 09/15/13. Physician's Order dated 01/04/14 documents wound care with Kerlex and Normal Saline every day. Review of the Nursing Shift Assessments and Nurses Notes dated 01/05/14 thru 05/27/14 failed to provide evidence the treatment was provided daily as ordered. The nursing assessments failed to document daily assessment for the buttock wound and progression of the wound.

In addition the patient's clinical record documents discrepancies regarding the type of wound to the left buttock. Operative Report dated 01/04/14 documents "abscess wound to the left buttock" was found to be a large hematoma. Operative Report dated 01/13/14 documents patient has a decubitus ulcer which continues to be contaminated with stool. Wound Care Consult dated 01/23/14 documents the wound is a hematoma, status post incision and drainage. Nursing shift assessments dated 01/10/14 documents the wound to the buttocks is non-pressure related; Nursing shift assessment dated 02/05/14 documents the wound is a stage IV pressure ulcer; Nursing shift assessment dated 02/07/14 documents stage III to the left buttocks. Physician's progress notes dated 06/28/14 documents Stage IV to coccyx now healed.

Physician's order dated 06/28/14 documents wound care consult for "stage I was being documented, but it is more a stage II", Please evaluate. The record presents no evidence the wound consult ordered 06/28/14 was completed as of 07/30/14.
Interview with The Director of Trauma Intensive Care and Trauma Step-Down Unit conducted on 07/30/14 at 3:04 PM revealed Patient # 6 had an abscess to his buttocks; it was not a pressure ulcer. The Director acknowledges the documentation of the wound and treatment is not consistent or accurate. In addition, The Director explained the documentation related to a stage I and II pressure ulcer on 06/28/14 may have been an error, and when the wound nurse followed up there was no wound and therefore no documentation.


(5) Patient #5 was admitted to the facility on 07/26/14. Medication Administration Record dated 07/29/14 and 07/30/14 documents the patient was medicated for pain with Oxy IR 10 mg by mouth on 07/29/14 at 4:53 AM and 10:48 PM and on 07/30/14 at 2:20 AM. In addition the patient was medicated with Dilaudid 1 mg intravenously on 07/29/14 at 11:11 AM and 8:30 PM and on 07/30/14 at 12:07 AM. The record provides no evidence a pain reassessment was completed as per facility protocol, subsequent to the administration of pain medication. Facility policy titled "Pain Management" documents All PRN analgesia administered will be documented on the medication administration record. All patients will be reassessed for pain within one hour after pain treatment/interventions have been administered.

Interview with The Clinical Coordinator, who was navigating the electronic record, with the surveyor, conducted on 07/30/14 at approximately 3:30 PM, revealed the electronic system has multiple areas for documentation; The Coordinator was not able to locate and provide evidentiary documentation for the concerns identified above.

Interview with The Assistant Director of Nursing, The Director of Trauma Intensive Care and Step-down and The Quality Coordinator was conducted on 07/31/14 at approximately 11:30 AM. The management staff reviewed the clinical records for Patients #1, #2, #4, #5, and #6 and no additional documentation was provided related to the skin assessments, provision of wound care and pain reassessments identified above.

Based on policy review, clinical record review and staff interview the facility failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) F. S. for 2 of 3 sampled patients (Patients # 8 and #9) as evidenced by failure to monitor vital signs after blood transfusions as specified per facility policy.


The Findings include:


Facility Policy titled Blood Administration and Protocol last reviewed 05/2014 documents, vital signs will be performed as listed below and PRN (when necessary) during blood transfusions.
a. 15 minutes after start of transfusion.
b. Full set of vitals at the completion of the transfusion (temperature, pulse, blood pressure, respirations and pulse oximetry reading).
c. A full set of vitals 30 minutes after the transfusion has completed (temperature, pulse, blood pressure, respirations and pulse oximetry reading).


Clinical record review on 07/31/14 revealed the following:
Transfusion Record for Patient #8 documents blood transfusion was administered on 07/22/14. At the time of review the record failed to yield evidence a complete set of vital signs was completed thirty minutes after the blood transfusion was completed (per facility policy).

Transfusion Record for Patient #9 documents a blood transfusion was administered on 07/20/14 to the patient. The review of the record failed to provide evidence substantiating a complete set of vital signs was done when the transfusion was completed, and thirty minutes after the completion.

Interview with the Assistant Director of Nursing, the Director of Trauma Intensive Care and Step-down and The Quality Coordinator was conducted on 07/31/14 at approximately 11:30 AM. The management staff reviewed the clinical records for Patients # 8 and 9 and no additional documentation was found or provided related to the post blood transfusion assessments including a complete set of vital signs identified above.