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Based on observation, record review and interview; the facility was found to be out of compliance with the requirement to prepare Comprehensive Care Plans for 2 of 5 sampled patients. (patients #1 and #3)

Findings:

On 4/21/2010 an unannounced complaint survey was conducted at the facility (CCR#2010003923), with allegations related to pressure ulcer prevention and treatment.

1) An observation of wound care for patient #1 was conducted at 10:45 AM . Patient #1 was noted to have a diagnosis of a Stage IV sacral wound and was observed to have a wound vacuum system in place. 2 Registered Nurses and the patient's Physician Assistant (PA) were at bedside and performing the wound vacuum dressing change. The old dressing was removed and the wound was cleansed. The wound appeared to be of significant size and depth. During the procedure the RNs were asked about the frequency of wound care measurements or other methods to document wound condition. Neither of the RNs could answer how often to conduct measurements, but the PA replied the measurements should be obtained every 3 days when the wound vacuum is changed and per the facility policy or patient's care plan. A wound measurement grid was obtained and the length and width measurements were obtained at 10 cm wide by 14 cm length, however no depth was assessed.

A record review of patient #1's Skin Assessment form (MHMC 442) revealed an initial admission entry on 4/10/2010 as "stage IV wound to sacral area. Area 10 cm X 14 cm, wound vac, dressing changed Q 3 days, 5 cm width and 15 cm length." An additional entry dated 4/11/2010 as "tissue and muscle seen decubitus is 15 cm length and 5 cm in width, appears to be 1-1 1/2 inches deep." There are no additional measurements of the wound and appears the depth was only and estimate.

A record review of patient #1's Care Plan for "Skin/Wound" dated 4/10/2010 revealed a Desired Outcome of "maintains integrity of skin, demonstrates progressive healing of existing incisions/wound/stoma surgical or non-surgical." The interventions were noted as "Perform focused skin assessments as clinically indicated, Initiate skin integrity care plan." The Care Plan failed address the patient's admission and current wound condition and lacked specific interventions related to dressing changes and wound measurements, and lacked evidence of interdisciplinary efforts.

A record review of the facility's Policy and Procedure for "Wound Care: Sterile Dressings" effective 1/1994, revealed the policy directed staff to "documentation: record time of dressings applied, duration of treatments, solution used, color, odor, and amount of drainage from wound; appearance of wound and any other pertinent information."

An interview was conducted at 11:30 AM with the facility's Chief Nursing Officer and she reviewed the Policy, Care Plan, and Skin Care document, and indicated the policy was "vague" and did not provide clear directives to nursing staff on how or when to conduct wound care measurements and the Care Plan also lacked any specific directions for nursing staff to meet the patient's needs.

2) The closed medical record for patient #3 was obtained and revealed the patient was admitted on 3/23/2010 with diagnosis of dysphagia, weakness, anorexia, and fever. The patient received intravenous fluids, Speech Therapy, pureed diet, and then on 3/26/2010 was moved from an inpatient to a Swing Bed status. On 3/30/2010 the nursing notes revealed blister type areas on the coccyx area and orders were obtained for Lantiseptic cream to coccyx and buttocks daily in AM and PRN. On 4/4/2010, the Skin Assessment document revealed the patient now had a Stage II wound gluteal fold and coccyx. On 4/6/2010 the Skin Assessment document and nursing notes revealed orders for wet to dry dressings to the Stage II area.

The patient's Care Plan dated 3/23/2010 lacked any Desired Goal or Interventions for Skin or Wounds throughout the patient's admission and discharge on 4/8/2010.

An interview with the Chief Nursing Officer was conducted at 11:30 AM and she concurred the patient's skin and wound conditions should have been identified and included in the plan of care.

Correction date May 21, 2010