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Based on clinical record review, policy review and interview, it was determined of the 10 records reviewed, 5 had identified skin impairment. In three (#1, #4 and #7) of five (#1 and #4-#7) patients, the nursing staff did not assess all characteristics of the skin impairment to ascertain if the wound remained stable, declined or improved. In five of five (#1 and #4-#7) patients, the nursing staff did not develop a plan of care to improve or prevent a decline in the identified wound. The failed practice had the likelihood to affect any patient identified with skin impairment. The findings were:

1. Patient #1 and #4-#7 had identified skin impairment. The nursing staff did not assess all characteristics of the skin impairment to determine if the wound remained stable, declined or improved. For example: Patient #4 was admitted on 08/15/16. Review of the "Legend Wound, Lesions, Scars-Date each findings" revealed wounds were identified on the anatomical drawings but identifying the date of awareness was difficult as all wounds were on one sheet with no clear dates. The identified areas of skin impairment included: Redness to scrotum, buttocks and rectum; sacral area circled with redness identified; abrasion of the back of the right elbow; scattered bruises on the right forearm; scattered bruises on the left forearm; open blister on left heel (identified on 08/21/16); and purple boggy area on right heel. There was assessment to include the size, depth, drainage, etc. There was no assessment as to whether the skin impairment was pressure ulcer related or due to another cause. Review of the "Phases Daily Shift Assessment" 08/16/16 to 09/05/16 revealed there was no assessment for all characteristics of the wounds.
2. The plan of care for Patient #1 and #4-#7 did not include care for the identified skin impairments.
3. Review of the Skin Care Policy revealed:
A. "4. Classify pressure sores (decubitus) using four stage classification system:"
B. "5. Note the following when assessing the pressure sore:
a. Condition-Whether the area is clean, granulating surface or one covered with feces, drainage or necrotic debris
b. Location-Perineum or other soft, most places may be difficult to manage
c. Size-Measure the area upon initial assessment and as ordered/needed".
C. The policy did not address any other type of skin impairment related to assessment and/or treatment.
4. The Chief Nursing Officer (CNO) confirmed the findings in "1 and 2" for Patient #1 (09/07/16 at 1115), #4 (09/07/16 at 1226), #5 (09/07/16 at 1230) and #6 (09/06/17 at 1230) and #7 (09/07/16 at 1245). The CNO confirmed the findings for the Skin Care Policy in "3".


Based on clinical record review and interview, it was determined the Individual Interdisciplinary Treatment Plan was in a standardized format and not individualized to meet the patient's needs for 10 of 10 (#1-#10) patients. The failed practice had the likelihood to affect any patient admitted to the Unit. The failed practice did not assure each patient's individual strengths and weaknesses were used to develop the plan of care to improve their status for discharge. The findings were:

1. Review of the Individual Interdisciplinary Treatment Plan for Patient #1-#10 revealed they were a standardized format with all interventions checked without relating back to why the patient was there or their ability to participate in therapy. For example:
Patient #8-Review of the Individual Interdisciplinary Treatment Plan initiated on 05/16/16 and the Master Treatment Plan initiated on 05/16/16 revealed:
A. The problems were combativeness, agitation, hallucinations as related to altered thought process and wandering behavior and/or restlessness.
B. The plans were in standardized format which were initiated by the Social Worker. For each problem every intervention was checked indicating they were active which was not individualized per the patient. For example: an intervention for combativeness was individual therapy session (blank space) times per week. The blank space was to be filled in but there was a dash. During an interview on 09/07/16 at 1034, the Social Worker was questioned regarding the "Xs" beside the intervention. The Social Worker confirmed the "Xs" indicated the intervention was to be implemented. The Social Worker was then questioned regarding not filling in the blank space for individual therapy session. The Social Worker stated individual sessions were not done. Social Worker was then asked why an "X" was placed in front of the intervention. Social Worker stated that during her orientation/training she was told to place an "X" for each intervention.