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Based on observation, record review and interview, the facility failed to document assessment, planning, intervention and evaluation of care for 1 of 1 sampled patients by failing to assess and document status of pressure ulcer in accordance with professional standards of quality.

The findings were:

A record review of patient #1 revealed an admission date of 5/26/10 with a Stage 2 pressure ulcer to left buttock. Physician's orders dated 5/26/10 to cleanse with normal saline, then apply Duoderm to left buttock stage 2 wound. Facility's wound assessment form indicates the wound measuring 0.5cm x 0.4cm x 0.1cm on 5/26/10. There are no further assessments or measurements documented for this wound as confirmed by interview with Chief Nursing Officer (CNO) at approximately 10:00 AM. The CNO stated she has not conducted random chart review relating to compliance with wound care policy as stated in the facility's plan of correction.

Review of th facility's Policy and Procedure titled "Pressure Ulcer Treatment" and dated 5/17/10 stated to assess pressure ulcer by using wound assessment form weekly, prn and change in condition. Review of patient's plan of care for Stage 2 ulcer of left buttock was conducted at approximately 10:15 AM. Plan of care documented the following under staff implementation: Assess pressure ulcer by using wound assessment weekly or if significant change. Interview with CNO confirmed weekly wound assessments and measurements had not been done.

Observation of wound care performed on 6/7/10 at approximately 11:00 AM revealed the left buttock area reddened with skin intact. A duoderm dressing was removed by a licensed nurse revealing a midline coccyx stage 2 ulcer measuring 0.5cm x 0.4cm x 0.1cm. The licensed nurse was unsure if the stage 2 pressure ulcer to left buttock on admission had healed or whether the ulcer to the coccyx developed after admission

"Professional standards of quality" means services that are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.

Correction Date: 7/8/2010