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Based on the findings of the complaint investigation concluded on 01/16/14, it was determined the Condition of Participation for Provision of Services was not met. Through clinical record review, staff interview and review of the facility's policies it was determined the facility failed to ensure staff completed an integumentary (skin) assessment with interventions for patients admitted (C0296). The facility failed to develop care plans, with interventions, for patients with skin breakdown and/or who had the potential for skin breakdown.

Refer to Standards C0296 and C0298.

Based on interview, record review and review of facility policy it was determined the facility failed to ensure a Registered Nurse (RN), or other licensed practitioner, supervised and evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #1). The facility admitted Patient #1 on 12/27/13 and obtained pictures of the patient's skin upon admission. A review of the pictures revealed the patient had impaired skin to the sacrum (buttock area), groin, and abdominal areas at the time of admission. However, interviews and documentation revealed facility staff failed to accurately assess and document the areas, failed to develop a plan of treatment with interventions related to the impaired skin integrity, failed to notify the patient's physician of the areas, and failed to provide treatments to the wounds for a timeframe of three days after the patient's admission.

The findings include:

Review of the facility policy, "Admission of a Patient to a Unit," with a revision date of December 2012 revealed the nurse that admitted a patient to the facility was required to complete an admission assessment and initiate a nursing care plan on the patient. The policy revealed a Registered Nurse (RN) was to supervise the patient's initial assessment. According to the policy, the nurse's assessment was required to include the condition of the patient at the time of admission, including state of consciousness and condition of the skin.

The facility admitted Patient #1 on 12/27/13 with a diagnosis of Gastrointestinal Bleed. Documentation by RN #1 on an admission assessment dated 12/27/13 revealed the patient did not have any wounds upon admission. Further review of Patient #1's medical record revealed on 12/27/13 nursing staff conducted a skin assessment and noted Patient #1's skin was intact with no pressure ulcers present upon admission, and the patient's right and left heels were "mushy." However, a review of pictures taken by RN #1 of Patient #1 on the day of admission to the facility, 12/27/13, revealed the skin on the patient's left and right sides of the groin area was broken; the skin fold under the patient's abdomen was red and excoriated; and although the patient's sacrum area was intact, the area was red, purple, and black in color. On 12/28/13 and 12/29/13, facility staff conducted a skin assessment of Patient #1 during the 7:00 AM-7:00 PM shift, and again on the 7:00 PM-7:00 AM shift. Based on the documentation, staff noted the patient did not have skin breakdown upon admission to the facility and noted the patient's right arm had a skin tear. Again on 12/30/13 at 7:36 AM, facility staff conducted a skin assessment of Patient #1 and noted the patient did not have any skin breakdown upon admission and was noted to have a skin tear on the right arm. In addition, a review of documentation revealed from 12/27/13 to 12/30/13 three Registered Nurses (RNs) assessed the patient on six occasions and failed to develop and/or implement interventions related to skin breakdown, even though the patient was assessed to be at risk for skin breakdown and had a skin tear on the right arm. From 12/27/13 to 12/30/13, Patient #1's skin was assessed six times. Continued review revealed on 12/30/13 at 8:30 AM the facility's wound care nurse assessed Patient #1 and documented the patient had two wounds present to the sacral area at that time that were assessed to be Stage III (full thickness tissue loss). In addition, the wound care nurse documented Patient #1 had abrasions on the right and left sides of his/her groin area. Based on a review of documentation, the wound care nurse noted the patient's wounds and abrasions were not "new wounds."

A review of facility Treatment Administration Records revealed the facility failed to provide treatments to the skin breakdown on Patient #1's sacrum, groin, or abdominal areas until after the wound care nurse conducted an assessment of Patient #1's skin on 12/30/13, three days after the patient was admitted to the facility. In addition, a review of a picture obtained by the facility and dated 12/30/13, three days after the patient's admission to the facility, revealed the skin on the patient's sacrum was broken, and staff had assessed the area as a Stage III pressure wound.

Interview with Registered Nurse (RN) #1 on 01/15/14 at 4:24 PM revealed the RN admitted Patient #1 on 12/27/13. RN #1 stated she took pictures of Patient #1's sacrum, groin area, and abdominal folds upon admission due to the skin impairment. The RN stated the patient was admitted with the areas but the skin was not open. Further interview revealed the RN "forgot" to document the skin breakdown when she documented the status of the patient's skin based on the skin assessment. The RN further stated she did not notify the patient's physician of the areas on Patient #1's skin or obtain an order for treatment for the areas at the time of admission because "there wasn't anything actually open" on Patient #1's skin.

Interview on 01/15/14 at 2:24 PM with the Director of Nursing (DON) revealed it was the responsibility of the nurse that admitted the patient to the facility to assess and evaluate any skin issues, notify the physician to obtain orders, provide care, and develop a care plan with interventions for any wounds the patient may have until the wound care nurse could assess the patient. The DON further stated the nurse that admitted the patient was responsible to perform a wound assessment on any and all wounds a patient had when he/she was admitted to the facility. The DON further stated she thought the floor nurses were "depending on the wound nurse too much," and "leaving it all to her" to assess and evaluate each wound.

Based on observation, record review, interview, and review of policy and procedure it was determined the facility failed to develop and implement a plan of care for five (5) of ten (10) sampled patients that were admitted with or assessed to have impaired skin integrity (Patients #1, #2, #6, #7, and #8). The facility failed to assess risk factors associated with the development and/or worsening of the impaired skin integrity for each individual patient. In addition, the facility failed to implement, based on an established plan of care, measures to prevent the development and/or worsening of the identified risk or impaired skin integrity. Continued review of documentation revealed Resident #1 experienced a decline of skin integrity, and Patient #2 developed two Stage I pressure areas during the patient's admission to the facility.

The findings include:

Review of the facility's "Wound Care Policy Prevention and Treatment of Pressure Ulcers" revised 08/14/13, revealed each patient would be assessed upon admission for existing skin problems and the potential risks of developing pressure ulcers. A patient with a score less than or equal to 18 on the Braden Scale (an assessment tool used to determine a patient's risk for pressure ulcer development) would be considered at high risk for the development of skin breakdown during the hospitalization, and a plan of care would be developed. Patients admitted to the facility with skin breakdown or who developed facility acquired skin impairment would be referred to the facility's wound care nurse.

Review of the facility's policy, "Admission of a Patient to a Unit," revised December 2012, revealed the nurse that admitted a patient to the facility was required to complete, at the time of admission, an assessment of the patient and was to initiate a nursing care plan. The nurse's assessment was required to include the condition of the patient at the time of admission, including state of consciousness and condition of the skin. In addition, the policy revealed the initial assessment was required to be supervised by a Registered Nurse (RN).

1. A closed record review was conducted and revealed the facility admitted Patient #1 on 12/27/13 and discharged the patient on 01/03/14. Review of Patient #1's medical record revealed the facility admitted the patient on 12/27/13 with a diagnosis of Gastrointestinal Bleeding. A review of the facility's admission assessment conducted by RN #1 revealed the patient was assessed to have a score of 11 on the Braden Risk Assessment Scale (an assessment of the patient's risk for the development of skin breakdown) and revealed Patient #1 was "considered at risk (for skin breakdown) and appropriate interventions implemented." Further review of the admission assessment revealed RN #1 had assessed Patient #1 to have no wounds; however, review of photographs obtained by RN #1 on the day of the patient's admission to the facility, 12/27/13, revealed evidence of broken skin in the groin area, bilaterally, and the skin under the abdomen was red and excoriated. The photograph also revealed that, although Patient #1's skin was not open over the sacrum, the area was deep red, purple, and black in color.

A review of Patient #1's admission care plan revealed the facility failed to develop or implement interventions to address Patient #1's impaired skin integrity or interventions in an effort to prevent worsening or the further development of skin breakdown.

An interview was conducted on 01/15/14 at 4:24 PM with RN #1 who admitted Patient #1 to the facility. RN#1 stated she "forgot" to document the areas of impaired skin integrity on Patient #1's sacrum and groin area and stated that care plans were developed based on the patient's admitting diagnoses. RN#1 stated she "could have" developed a care plan to address the areas of skin breakdown on Patient #1's sacrum and groin area and could have developed risk factors that placed the patient at risk for the development of and/or further skin breakdown, but did not "usually" develop a plan of care for skin integrity. RN #1 stated it was not "mandatory" to develop a plan of care for patients who were determined to be at risk for skin breakdown, and therefore she did not develop a care plan related to Patient #1's skin integrity.

Review of documentation by the wound care nurse on 12/30/13 (three days after the patient's admission to the facility) and review of a photograph dated 12/30/13 (three days after the patient's admission) revealed the skin tissue on Patient #1's sacrum had opened and was classified as a Stage III pressure wound. However, a review of documentation on the patient's care plan revealed the wound care nurse failed to ensure a plan of care, with interventions, was developed to address the Stage III pressure area on the patient's sacrum or Patient #1's risk factors for the development of further skin breakdown after her assessment of the patient.

2. Review of the medical record revealed the facility admitted Patient #6 on 01/10/14 due to shortness of breath and increased heart rate. Review of the admission assessment performed by Registered Nurse (RN) #4 revealed the patient had a score of 13 on the Braden Risk Assessment Scale, and would be "considered at risk (for skin breakdown) and appropriate interventions implemented." Additionally the admission assessment revealed Patient #6 had "multiple scab wounds" to the lower extremities bilaterally. Patient #6 was also assessed to require compression stockings (specialized stockings designed to help prevent the occurrence of disorders in the venous circulatory system, e.g., blood clots). However, the facility failed to ensure a care plan, with interventions, was developed and kept current that addressed Patient #6's risk for skin breakdown, the "multiple scab wounds" on the resident's lower extremity, or the use of the compression stockings.

An interview on 01/16/14, at 12:00 PM with RN#4, who completed the admission assessment for Patient #6 on 01/10/14, revealed the RN could not recall Patient #6. According to RN #4, she routinely addressed wounds when she conducted an admission assessment. The RN stated that if a patient received a score of 18 or less on the Braden Assessment Scale, a consultation with the wound care nurse was generated, but a plan of care would not be developed. RN #4 stated that care plans were developed for admitting diagnoses only stating, "That is just common sense." RN #4 stated that if an area of skin impairment was identified on the admission assessment, the physician would not be contacted because "they would have just seen them in the ER (Emergency Room) or their office," and should "already know about it."

Review of documentation revealed the wound care nurse assessed Patient #6 on 01/13/14 and noted the patient had compression stockings in place and had scabbed areas present to the lower extremities. Additionally, the wound care nurse documented a "small dry abrasion" was observed on the lateral aspect of the resident's right foot. However, the wound care nurse failed to ensure a care plan, with interventions, was developed to address the scabbed areas on the patient's legs, the use of the compression stockings, or the "small dry abrasion" located on the lateral aspect of the patient's foot in an effort to prevent worsening or the further development of skin breakdown.

A skin assessment with the assistance of facility staff was conducted of Patient #6 on 01/14/14, at 5:15 PM and revealed multiple areas of scabbed skin to both feet and toes and a small dry yellow area on the lateral aspect of the patient's right foot. Patient #6 was observed to have compression stockings in place and when removed from the right extremity by facility staff, observations revealed a red, indented area around the resident's right foot, near the toes, where the elastic rim of the compression stockings had been worn. According to RN #7, the compression stockings "were too tight."

3. Review of the medical record revealed the facility admitted Patient #7 on 01/06/14 due to weakness, inability to ambulate, and poor nutritional intake. Review of the Admission Assessment for Patient #7 dated 01/06/14, revealed staff assessed the patient to have a score of 17 on the Braden Assessment and was not observed to have any wounds present at the time of admission. Additionally, Patient #7 was assessed to require compression stockings bilaterally to the lower extremities. Further review of Patient #7's medical record revealed due to the patient's score on the Braden Assessment, a care plan was required to be implemented to address the patient's risk of skin breakdown. However, the facility failed to ensure a care plan was developed, with interventions identified and implemented, to address the patient's risk of skin breakdown.

Interview with RN #2 revealed she had completed the admission nursing assessment for Patient #7 on 01/06/14 and stated she had not developed a care plan, with interventions, to address the patient's risk for skin breakdown at the time of her assessment. According to RN #3, she "assumed" the wound care nurse would evaluate Patient #7's skin and create a care plan to address the patient's risks.

Review of documentation revealed the wound care nurse assessed Patient #7 on 01/07/14, one day after the patient's admission, and noted Patient #7's skin on the right foot was "very dry" and "peeling from the toes." The assessment indicated compression hose had been in use, but Patient #7's bilateral heels and left lateral foot and ankle were reddened and the right heel remained "dark red." The wound care nurse identified the area to Patient #7's left heel as a Stage I pressure area (a nonblanchable area of skin that is not open). Based on documentation, the physician was notified and an order was obtained to remove the compression stockings due to redness of the patient's heels and feet, and the risk for pressure areas. The nurse's assessment also revealed Patient #7 had a history of skin breakdown to the coccyx area and described the "healed" areas as "dark pink shiny spots with dry tan scabs." The wound care nurse's documentation also revealed the areas were "likely from friction/shearing occurring during turning." The wound care nurse documented that Patient #7 required "frequent inspection" due to the risk of skin breakdown; however, a review of the care plan revealed staff, including the wound care nurse, failed to develop a care plan, with interventions, to address the patient's skin breakdown or the risk of further skin breakdown.

A skin assessment conducted on 01/14/14, at 5:00 PM revealed the patient's skin was dry and a small red scabbed area was observed on the patient's right ankle. The patient's heels were red, boggy, and slow to blanch. The area located on the bottom of the patient's left forearm was observed to be red and excoriated. In addition, Patient #7's buttocks were dark red, slow to blanch, and dry and flaky with broken areas present.

4. Review of the medical record revealed the facility admitted Patient #2 on 01/12/14 due to nausea and vomiting. Review of the Admission Assessment performed by RN #3 revealed the patient had been assessed to have a score of 12 on the Braden Risk Assessment, and according to the assessment, was "considered at risk (for skin breakdown) and appropriate interventions (would be) implemented" by staff. Additionally the facility assessed Patient #2 to require compression stockings. However, the facility failed to assess Patient #2's individualized risk factors for skin breakdown, to include the use of the compression stockings, and failed to develop a plan of care with interventions to prevent skin breakdown for Patient #2.

Review of nursing documentation dated 01/13/14 at 7:05 PM revealed Patient #2 complained that the compression stockings were "uncomfortable." Documentation revealed the nurse removed the stockings and observed redness to the patient's right leg below the knee and bilateral feet at the base of the toes, and staff requested the facility's wound care nurse to assess the patient. Documentation dated 01/13/14 at 7:25 PM, revealed the wound care nurse assessed Patient #2 and documented the patient had a Stage I pressure area to the right leg, secondary to the compression stockings. However, the facility failed to develop a care plan, with interventions, to address Patient #2's skin breakdown to the lower right leg and the use of the compression stocking.

Interview on 01/16/14 at 10:20 AM, with RN #3, who completed the admission assessment for Resident #2 on 01/12/14, revealed that although the resident had been identified to be at risk for skin breakdown, she did not develop a plan of care to address the patient's risk factors for skin breakdown or to develop/implement interventions to reduce the risk of skin breakdown for Patient #2. RN #3 stated she had been instructed during "electronic medical records training" to develop only care plans relevant to the patient's admitting diagnoses.

Observation of a skin assessment conducted by the facility's wound care nurse on 01/14/14, at 3:30 PM revealed Patient #2 had a nickel-sized red area, with a nonblanchable center, to the lower lumbar spine. At the time of the assessment, the wound care nurse documented the area on the patient's lower lumbar area as a Stage I pressure area that had not been identified previously. Review of physician's orders dated 01/14/14 at 3:50 PM revealed orders were received to begin treatment to the pressure area on Patient #2's lower lumbar spine.

5. A closed record review was conducted and revealed the facility admitted Patient #8 to the facility on 01/05/14 with a diagnosis of pneumonia. Review of the Admission Assessment performed by RN #5 revealed Patient #8 scored 7 on the Braden Risk Assessment and was "considered at risk" (for skin breakdown) and appropriate interventions implemented." Additionally the facility assessed Patient #8 to require compression stockings. However, the facility failed to assess Patient #8's individualized risk factors for skin breakdown, including the use of the compression stockings, and failed to develop a care plan, with interventions, in an effort to prevent skin breakdown for Patient #8.

Interview on 01/14/14 at 11:44 AM with RN #5 revealed she had completed the admission assessment for Patient #8 and stated if a patient scored below 18 on the Braden Risk Assessment, a consultation with the wound care nurse would be requested. Therefore, RN #5 stated care plans to prevent potential skin breakdown were "not developed as much as they should be" by facility staff.

Review of documentation revealed the wound care nurse completed a wound care assessment of Patient #8 on 01/06/14, one day after the patient's admission, and noted Patient #8 was incontinent and had reddened buttocks. However, based on review of the assessment, the facility failed to develop an individualized care plan, with interventions, for Patient #8 related to the patient's assessed risk for the development of skin breakdown.

Interview with the wound care nurse on 01/15/14 at 5:00 PM revealed a consultation for wound care was automatically generated for any patient who scored 18 or below on the Braden Risk Assessment. According to the wound care nurse, the results of the consultation would determine if a wound care consultation was required for the patient. The wound care nurse stated when she received a consultation for a wound care assessment, she evaluated the patient. The wound care nurse stated she assessed the patient's skin intergrity but did not develop a care plan or interventions related to any skin impairment the patient was assessed to have. The wound care nurse stated nursing staff providing direct care to the patient would be responsible to develop and implement a care plan for the patient.

Interview on 01/15/14 at 2:24 PM with the Director of Nursing (DON) revealed it was the facility's policy and the responsibility of the nurse that admitted a patient to conduct an assessment of any wound the patient had upon admission to the facility, and if there were any skin issues identified, the nurse was to notify the physician to obtain physician orders and to develop a care plan to address the care and interventions for the wounds or potential for wounds. In addition, the DON stated nursing staff was to utilize the Braden Scale to determine each patient's potential for the development of skin breakdown. The DON stated she didn't "know" if a care plan was automatically generated by the computer system based on the results of the Braden Scale assessment. Interview with the DON further revealed the facility had recently implemented the computerized charting and "things" have "fallen through the cracks." According to the DON, the nursing staff was apparently "depending on the wound nurse too much," and "leaving it all to her" to assess and evaluate each wound.