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Based on interview, medical record review and review of hospital documents, it was determined that the hospital failed to ensure that the nursing staff developed, and kept current, a nursing care plan for each patient. The hospital's failure to do so resulted in a lack of a consistent plan to provide nursing care for 6 of 6 patients (Patients #1, 2, 3, 4, 5 and 6)whose medical records were reviewed. The hospital's failure placed all patients in the hospital at risk for incomplete and/or inconsistent nursing care due to a lack of a planned and cohesive approach to care, and may have contributed to the deteriorated skin condition of Patient #1.

Findings include:

Review of the medical record for Patient #1 revealed that there was no nursing care plan. No evidence was found in the record to support that nursing had evaluated the patient, identified her/his nursing needs and planned a consistent approach to meeting those needs.

In an email dated January 7, 2013, the Director of Quality Compliance (DQC) stated, "...Because of the way our EMR is set up there is not a single document that is the Nursing Care Plan. In the second set of documents I sent you under the title of " II. Daily Pt Documentation: " is the Nursing Asmt & Care Plan Note...".

The medical record of Patient #1 was reviewed by both investigators, in the presence of the DQC and the Director for Professional Services (DPS). No evidence was found to support that the patient had been thoroughly assessed relative to her/his skin status upon admission. There was no evidence to support that the nursing assessment had included the patient's risk for skin breakdown and what the nursing interventions would be to prevent/minimize skin breakdown or other trauma to the skin. Examples of such interventions would be the use of a pressure relief mattress, turning or repositioning the patient frequently, assessing fluid and nutrition status and needs and involving a wound care nurse if skin did break down.

Medical records were obtained from the skilled nursing facility (SNF) that had received Patient #1 upon her/his discharge from the hospital. The SNF records documented that, upon admission to the SNF, the patient was found to have 10 bruises that had not been present when the patient was sent to the hospital. The bruises included, but not limited to, a 5.5 by 1.5 centimeter (cm.) bruise to the abdomen: 6 by 3 cm. and 13 by 10 cm. and 5 by 3 cm. bruises to the left arm; a 7 by 6 bruise to the top of the left great toe and more.

The medical record also documented that the patient had open areas of skin which were not present when the patient was initially sent to the hospital. The open areas included a 6 by 5 cm. area of necrotic tissue (dead and nonviable tissue) on her/his left heel, a decubitus ulcer, unmeasured, on the right heel and a 1/2 by 1 cm. area of open tissue around the tip of the penis.

Review of the patient's hospital medical record revealed that the patient appeared to have entered the hospital with intact skin, as no documentation was found in the hospital record that identified areas of skin breakdown upon admission.

Review of all 6 patient medical records revealed that interventions to prevent and treat skin breakdown were located in multiple locations. The DQC acknowledged that the patient record did not provide an effective clinical tool for tracking and monitoring both the prevention and management of skin breakdown. None of the 6 medical records contained a nursing care plan.

The DPS stated that the risk of skin breakdown was assessed on every patient using the Braden Score "once a shift". S/he identified "once a shift " as every eight hours. On interview, 3 staff Registered Nurses (RNs) RNs #2, #3 and #4) stated that they performed this assessment once every twelve hour shift.

The Director of Acute Care Services (DACS) stated that rounds were made on a medical-surgical nursing unit approximately once every other month. All patients on the unit were then assessed for the presence of skin breakdown at that time. No reference was made regarding whether measures to prevent skin breakdown or care plans were assessed as part of these rounds.

Review of the hospital's policy "Patient Care Planning" revealed that the document stated the following:

"SCOPE: PeaceHealth patient care providers, nurses, interdisciplinary caregivers, patients, and patients' family/primary support person.

PURPOSE: An individualized plan of care for each patient is developed by the Patient Care Team in order to meet the following goals..."

The policy did not call out how the nursing staff was to develop and keep current, a nursing care plan for each patient, a plan specific to the nursing needs of the patient.

The "Departmental Scope of Services" was also reviewed. The section "METHODS USED TO ASSESS AND MEET PATIENT'S NEEDS" stated the following:

"On admission to the unit, an admission history is completed within eight hours. The assessment includes a physical assessment of systems, current and past medical history, nutrition and safety/risk assessment, and psychosocial, cultural, spiritual and age-specific needs. Problems are identified in an interdisciplinary care plan and a teaching plan is developed. Various disciplines involved include physicians, spiritual care, dietary, care management, respiratory care, rehab services and discharge planning.

The care plan is evaluated and modified as necessary on each shift. Each patient is assessed at least every 12 hours with a focused reassessment every 6 hours, however patient condition and status dictates the frequency of the assessments."

The document does not direct nursing services to do the initial nursing assessment of the patient, nor does it direct nursing services to develop a nursing care plan for the patient. The specific role of nursing is not address in the section reviewed.

During discussion of the Federal requirement for a nursing plan of care, discussion was also held regarding the Washington State requirement that only RNs conduct assessments and reassessment of patient's nursing care needs.