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Based on record review and interview, the hospital failed to develop a timely pressure ulcer treatment plan of care for a patient admitted with bilateral heel pressure ulcers by not performing a documented assessment of the pressure ulcers at admission, and by not obtaining physician treatment orders for those pressure ulcers at admission (#4). The hospital did not develop a plan of care for a new right foot pressure ulcer by not notifying the physician and obtain treatment orders for the new wound (#4). The hospital did not develop a treatment plan for the use pressure relieving multi-podus boots for a patient with bilateral heel pressure ulcers by not acknowledging and/or clarifying orders for their usage (#4) for 1 of 4 sampled residents with pressure ulcers.


Findings:


1. Review of patient #4's admission nursing note dated 11/24/10 at 8:00 p.m. revealed that both heels had dressings on them. The medical record did not reveal that the nurse removed the heel dressings to assess the wounds underneath. The medical record did not reveal any evidence that the wounds underneath the heel dressings had been described, measured, staged, or treated from 11/24/10 -11/27/10. The medical record did not reveal any admission treatment orders for the heel wounds, only an order for a wound care evaluation and treatment.

Continued review of the medical record revealed that on 11/27/10, 3 days after admission, the hospital wound care nurse looked at the heel wounds, assessed both heel wounds to be unstageable pressure ulcers, and gave treatment orders. The wound care nurse assessment dated 11/27/10 revealed that both heels had unstageable pressure ulcers. The right heel measured at 5 centimeters (cm) by 3cm with a small amount of serosanguinous drainage. The left heel measured at 5cm by 4cm. Both heel wound beds measured at 90% eschar and 10% pink tissue. Treatment orders for the pressure ulcers dated 11/27/10 revealed the following: "Bilateral heels - paint with Betadine daily - may cover with Kerlix dressing".

Interview with the interim chief nursing officer (CNO) on 12/13/10 at about 2:00 p.m. validated the above findings. She stated that an assessment of the bilateral heel wounds should have been conducted at admission and treatment orders should have been obtained at admission.

2. On 12/13/10 at 12:30 p.m., observation of patient #4's the bilateral heel wound treatment with his floor nurse revealed that both heels had large unstageable black brown eschar pressure ulcers. At this same time, an additional black brown eschar area about 1.5 cm x 1 cm was noted on the outer edge of the bottom right foot. The nurse applied Betadine to the area. When asked, the nurse stated that it could have resulted from the family putting on the multi-podus boot when they came in to visit and that they were not to do that. Review of the medical record revealed that the right bottom outer foot wound had not been assessed at any time, nor had orders been obtained for treatment.

Interview with the interim CNO on 12/13/10 at 2:00 p.m. validated that there was not any documented evidence that the right bottom outer foot wound had been assessed or treatment orders obtained.

3. Continued review of patient #4's admitting orders dated 11/24/10 revealed that orders to use a specialty mattress, float the patient's heels, and to wear multi-podus boots. The orders did not indicate when the multi-podus boots were to be worn or for how long they were to be worn.

On 12/13/10 at 12:30 p.m., during a bilateral heel wound treatment observation with his nurse, the multi-podus boots were not part of the treatment. When asked about them, the nurse stated that the patient did not use them. The nurse also stated that the family put the boots on him when they came to visit and were not to do so.

Review of the physician orders from admission 11/24/10 - 12/13/10 did not reveal that the multi-podus boots had been discontinued as an order. They also did not reveal any documented evidence that they had attempted to clarify the multi-podus orders to reflect when and how long of a time the boots should be worn.

Interview with CNO and Chief Operating Officer on 12/13/10 at about 2:45 p.m. validated that there was not any documented evidence that the multi-podus boots had been discontinued or orders clarified for their use.

Based on interview, and record review, the hospital failed to ensure that a registered nurse instead of a licensed practical nurse performed the assessment function of the staging a pressure ulcer in accordance with the Florida Board of Nursing, Nurse Practice Act (#3); and did not ensure that the nurse performing a pressure ulcer treatment used aseptic technique while performing the treatment (#4) for 2 of 4 sampled patients with pressure ulcers.


Findings:

1. Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments.


Review of patient #3's medical record revealed that he was admitted to the hospital on 11/24/10 with diagnoses which included a pressure sore to the sacrum. Review of the form entitled "Photographic Wound Documentation" dated 11/24/10 revealed documentation that the sacral pressure ulcer measured at 10 centimeters (cm) in length by 4.5 cm in width by 3 cm in depth. The form documented the presence of undermining, drainage, slough, and eschar, and was documented to be a stage IV pressure ulcer. [A stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis,or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule).Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.] The form revealed that the pressure ulcer had been staged by a licensed practical nurse. Review of the 11/30/10 weekly pressure ulcer assessment also revealed that it had been staged by a licensed practical nurse.


On 12/13/10 at 3:20 p.m., interview with the hospital's quality assurance coordinator at and the interim chief nursing officer (CNO) validated that the act of staging a pressure ulcer is considered a nursing assessment and therefore the function of a registered nurse, not a licensed practice nurse. Both stated knowing that LPNs were not allowed to stage wounds.

2. On 12/13/10 at 12:30 p.m., observation of patient #4's bilateral heel pressure ulcer treatment with his floor nurse, a licensed practical nurse, revealed that each heel had a large unstageable black brown eschar pressure ulcer on them. The nurse used a Betadine swab and painted both heels with the swab. At this time, a third black brown eschar area about 1.5 cm x 1 cm was noted on the outer bottom area of the right foot. The nurse used the same Betadine swab and painted the additional wound. The wounds were left open to air and not covered by a dressing.

Review of patient #3's medical record revealed that the patient was incontinent of stool, had been diagnosed with the diarrhea causing organism, clostridium difficile (C-Diff), and had begun the antibiotic treatment, Vancomycin 250 milligram every 6 hours by mouth, for the C-Diff on 12/7/10 with the stop date of 12/21/10.

On 12/13/10 at about 3:00 p.m., interview with the hospital's infection control nurse preventionist and CNO stated that according to the hospital aseptic technique policy and procedure expectations and standards of practice, the nurse did not follow aseptic technique by using the same Betadine swab on each wound. She stated that the nurse should have used a separate Betadine swab for each wound to prevent any potential cross contamination. The CNO validated that the patient was being treated for C-Diff and was incontinent of stool. Review of the hospital's "Wound Care - Aseptic Technique" policy and procedures revealed that aseptic technique would be required during wound care.