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Based on observations, interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the hospital. The facility's Governing Body failed to function effectively to manage the hospital's compliance with Conditions of Participation (COPs) for Patient Rights and Nursing Services. The Governing Body failed to ensure sufficient nursing staff was available to provide resident care. The Governing Body failed to ensure the facility's policies and procedures prohibiting abuse/neglect were implemented.

On 03/12/15 at approximately 7:30 AM, Registered Nurse (RN) #1 was participating in a procedure with a physician on a patient. While she was assisting the physician, she passed the care of her remaining patients including Patient #1 to RN #2. At that point, RN #2 was responsible for the care of eleven (11) to twelve (12) patients on that floor of the facility. Certified Nursing Assistant (CNA) #2 was providing care for Patient #1 on 03/12/15. CNA #2 was responsible for fourteen (14) other patients on the floor as well. As a result of the facility's failure, Patient #1 developed wounds/pressure sores after being left on a bedpan for an extended period of time.

Patient #1 was found on a bedpan on 03/12/15 with skin breakdown in the shape of a bedpan. Direct care nursing staff reported to the Unit Manager that the resident had been left on the bedpan for an extended period of time resulting in skin breakdown to the buttock/coccyx area. The Unit Manager failed to enter the incident into the STARS reporting system (Facility #1's internal incident reporting system) according to facility policy. The facility failed to investigate the incident per facility policy, failed to report the incident to Administration and state agencies, and failed to protect patients from neglect by suspending the alleged perpetrators per facility policy. The facility failed to assess/monitor the skin breakdown/pressure area per facility policy and failed to notify the resident's physician of the new pressure area.

The failure of the facility to identify and adequately staff the facility with Registered Nurses and nurse aides, to provide necessary care, and to protect patients from neglect placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and was ongoing.

Refer to A0057.

Based on observations, interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The facility's Governing Body and Chief Executive Officer (CEO) failed to ensure sufficient nursing staff was available to provide necessary patient care. The Governing Body failed to ensure the facility's policies and procedures prohibiting abuse/neglect were implemented. On 03/12/15, Patient #1 was found lying on a bedpan with skin breakdown/discoloration to the buttock in the shape of a bedpan. Direct care staff reported the incident to supervisory staff and reported that the injury to the patient was from being left on a bedpan for an extended period of time. The facility failed to report and investigate the allegation of neglect per facility policy, and failed to protect patients during the investigation. The facility failed to investigate staffing related complaints and failed to identify that an insufficient number of staff working on the unit where Patient #1 resided potentially led to the injury of Patient #1 on 03/12/15.

The failure of the facility to identify and adequately staff the facility with Registered Nurses and nurse aides, failure to provide necessary care, and failure to protect patients from neglect placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and is ongoing.

The findings include:

On 03/12/15 at approximately 7:30 AM, Registered Nurse (RN) #1 was participating in a procedure with a physician on a patient. At that time, she passed the care of her remaining patients including Patient #1 to RN #2. At that point, RN #2 was responsible for the care of eleven (11) to twelve (12) patients on that floor of the facility. Certified Nursing Assistant (CNA) #2 was providing care for Patient #1 on 03/12/15. CNA #2 was responsible for fourteen (14) other patients on the floor as well. As a result of the facility's failure, Patient #1 developed wounds/pressure sores after being left on a bedpan for an extended period of time.

Patient #1 was found on a bedpan on 03/12/15 with skin breakdown in the shape of a bedpan. Direct care nursing staff reported to the Unit Manager that the resident had been left on the bedpan for an extended period of time resulting in skin breakdown to the buttock/coccyx area. The Unit Manager failed to enter the incident into the STARS reporting system (Facility #1's internal incident reporting system) according to facility policy. The facility failed to investigate the incident per facility policy, failed to report the incident to Administration and state agencies, and failed to protect patients from neglect by suspending the alleged perpetrators per facility policy. The facility failed to assess/monitor the skin breakdown/pressure area per facility policy and failed to notify the resident's physician of the new pressure area.

Interview with the Risk Manager on 04/02/15 at 12:15 PM revealed she heard about the incident in passing on 03/12/15, but the incident was never entered into the incident tracking system as per facility policy. The Risk Manager stated the facility had a policy to track, monitor, and report all incidents. She stated that the RN or Unit Manager should have entered the incident into the system, reported the incident to the patient's primary physician and, at that point, she would have been alerted by the incident tracking system and begun an investigation into the incident. The interview further revealed the Risk Manager stated the first knowledge she had that the issue was not resolved was when State Surveyors entered the facility on 04/01/15. The Risk Manager also stated the facility was having a difficult time recruiting and retaining nursing staff.

Interview with the Chief Nursing Officer (CNO) on 04/02/15 at 12:15 PM, revealed the Unit Manager had told her of the incident involving Patient #1 in passing around 03/12/15. She stated she followed up with the Unit Manager on 03/13/15 and was informed the incident had been resolved. The CNO stated the facility had a policy to track, monitor, and report all incidents. She stated that the RN or Unit Manager should have entered the incident into the system, reported the incident to the patient's primary physician, and at that point, the Risk Manager would have been alerted by the incident tracking system and begun an investigation into the incident. The CNO stated the first knowledge she had that the issue was not resolved was when State Surveyors entered the facility on 04/01/15. Continued interview revealed the facility was having a difficult time recruiting and retaining RNs and Certified Nursing Assistants. She stated the facility had recently hosted a job fair and it was not as successful as anticipated. She also stated nursing staff was working four days a week (four 12-hour shifts).

Interview with the Chief Executive Officer (CEO) on 04/02/15 at 12:15 PM revealed he was aware the facility was having a problem with staffing and that the facility was attempting to hire more nursing staff. The CEO said, "In the meantime they would just have to work with what they had."

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure patient rights were protected and promoted for one (1) of ten (10) sampled patients (Patient #1). On 03/12/15 at approximately 10:00 AM, Certified Nursing Assistant (CNA) #2 reported to Registered Nurse (RN) #2 that Patient #1 had a new wound/injury on the patient's buttocks in the shape of a bedpan. The injury was documented through photographs and reported to RN #1 who was the primary care nurse of Patient #1. RN #1 reported the wounds to the Unit Manager and informed the Unit Manager that Patient #1 was "left on a bedpan too long." The facility failed to immediately report the allegation of possible neglect to administrative staff and appropriate state agencies; failed to investigate the allegation of possible neglect; and failed to protect patients from neglect and identify alleged perpetrators.

Review of the medical record revealed Patient #1 was admitted to the facility on 02/16/15 with diagnoses that included Acute Renal Failure, Sepsis secondary to ulcers in the left leg, and Diabetes Mellitus Type 2. On 03/12/15 at approximately 10:00 AM, it was brought to the attention of RN #2 by CNA #2 that Patient #1 had a new wound on the patient's buttocks in the shape of a bedpan. RN #2 documented the wound through pictures and then reported the wound to RN #1 (Patient #1's primary nurse). RN #1 reported the injury/wound to the Unit Manager. There was no documented evidence the Unit Manager took any action regarding the report of possible neglect. There was no documented evidence the allegation of neglect was reported to Administration at Facility #1 until surveyors entered the facility. There was no evidence the facility initiated an investigation of the allegations until 04/03/15 (twenty-two days after the neglect occurred). CNA #1 and CNA #2 were suspended from direct care on 04/03/15 until the facility completed an investigation.

The failure of the facility to identify and protect patients from neglect and failure to ensure allegations of neglect were immediately reported, investigated, and patients were protected from further potential neglect placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and was ongoing.

Refer to A0145.

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to protect one (1) of ten (10) sampled patients from neglect (Patient #1). On 03/12/15, Registered Nurse (RN) #2 observed Patient #1's buttocks area and found a pressure sore/injury in the shape of a bedpan. RN #2 and Certified Nursing Assistant (CNA) #2 took a picture of Patient #1's injury and placed the picture in the medical record. RN #2 reported the new pressure sore/injury to RN #1 (who was Patient #1's primary nurse on 03/12/15). RN #1 reported the new pressure sore/injury to the Unit Manager on 03/12/15. The Unit Manager failed to enter the incident into the STARS reporting system (Facility #1's internal incident reporting system) according to facility policy. The facility failed to investigate the incident per facility policy, failed to report the incident to Administration and state agencies, and failed to protect patients from neglect by suspending the alleged perpetrators per facility policy.

The failure of the facility to protect patients from neglect and failure to ensure effective methods and mechanisms were followed to address timely reporting of allegations of neglect, to ensure a timely and thorough investigation of neglect allegations and protection of patients during neglect investigations, placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and is ongoing.

The findings include:

A review of the facility's policy titled "Patient Rights and Responsibilities" dated August 2005 revealed patients have the right to be free from verbal or physical abuse, negligence, or harassment while a patient in the facility.

A review of the facility policy titled "Suspected Abuse/Neglect/Exploitation of Patient and Reporting," dated June 2012, revealed the purpose of the policy was to ensure patients were free from all forms of abuse, neglect, harassment, or exploitation from staff, volunteers, other patients, or visitors. Furthermore, it is the policy of the facility that any person who knows or has reasonable cause to believe abuse, neglect, harassment, or exploitation of a child or adult exists shall immediately report the incident whether such occurred within the facility or prior to admission. The policy stated neglect was considered a form of abuse and was defined as the failure to provide goods or services necessary to avoid physical harm or mental anguish. Continued review of the policy revealed there would be adequate staff to ensure the care needs of every patient were met. If a staff member was identified, accused of an act of abuse, neglect, harassment, or exploitation as defined by this policy, the employee would be reassigned to a non-patient care area or placed on leave until cleared of the allegation. Allegations of abuse, neglect, or exploitation that were reported to have occurred while the patient was under the care of the facility were considered an unusual event. The policy stated the investigation would be conducted by the Risk Manager, and until the internal investigation was completed, the alleged victim would be protected from further harm.

A review of the policy titled "Incident Reporting," dated 07/01/04, revealed that reporting events that met the definition of incidents was the responsibility of all facility staff and physicians. An incident was defined as any occurrence that was not consistent with the usual operation of the facility or care of a particular patient. It was the policy of the facility to ensure proper and timely reporting of any occurrence on facility property that was not consistent with the usual operation of the facility or the care of the patient. An incident/event report was considered confidential and was maintained in a confidential manner within an electronic event reporting system. The procedure of the facility was defined as follows: A) Staff involved or witnessing an event shall complete an incident report. B) The Unit Manager would be contacted when an incident occurred. The Unit Manager would assess the patient and the circumstances surrounding the occurrence. C) The patient's primary care physician shall be contacted as soon as possible after the occurrence if the incident involved patient harm or potential harm. D) A complete review by the Unit Manager should be completed within 24 hours of the incident. After that time, the Risk Manger would review the incident report and follow up for completeness and recommend or conduct any further investigation that may be necessary. E) Completion of an incident report form does not preclude accurate documentation of the incident in the patient's record by standard documentation requirements.

Review of the medical record revealed Patient #1 was admitted to the facility on 02/16/15 with diagnoses that included Acute Renal Failure, Sepsis secondary to ulcers of the left leg, and Diabetes Mellitus Type 2. Continued review of the medical record revealed a picture taken on 03/12/15 of Patient #1's buttocks area that revealed an outline of a bedpan and pressure sores to the patient's coccyx area. There was no evidence in the record that revealed any documentation that Patient #1's physician was notified of the wound.

Interview with Physician #1 on 04/06/15 at 10:35 AM revealed that he was the primary physician for Patient #1 on 03/12/15. Physician #1 stated that he did not recall ever being informed of an injury to the patient's buttocks that happened due to remaining on a bedpan for an extended period of time. The interview further revealed at the time of the interview that he had not been asked to participate in or be a part of any facility investigation.

A review of the facility incident report dated 04/06/15 revealed the facility began an investigation into the incident on 04/03/15. The facility interviewed CNA #1, CNA #2, RN #1, and RN #2 and suspended CNA #1 and CNA #2 on 04/03/15. The investigation made initial recommendations that the facility would conduct global education on wound care, documentation, recognition, and escalating patient care issues. In addition, recommendations were made to educate on communication, shift change report, abuse and neglect, assessment and monitoring, and to follow up with progressive discipline of employees as the investigation continues.

Interview with CNA #1 on 04/02/15 at 11:10 AM revealed he was working the night shift on 03/11/15. He stated when he came on shift on 03/11/15 at 7:00 PM, CNA #2 told him in shift report that she had placed Patient #1 on a bedpan. Continued interview revealed that he took Patient #1 off the bedpan after shift change at approximately 7:30 PM. He stated that he turned and repositioned Patient #1 throughout the night and checked the patient's vital signs at approximately 6:30 AM on 03/12/15 and placed Patient #1 back on a bedpan per the patient's request. He stated he gave report to CNA #1 and informed her that Patient #1 was on a bedpan and needed to be removed.

Interview with CNA #2 on 04/01/15 at 5:00 PM revealed she was working on the day shift on 03/11/15 and 03/12/15. CNA #2 stated at approximately 6:45 PM on 03/11/15 she placed Patient #1 on a bedpan and when she went back to check on the patient he/she stated they were not finished. CNA #2 stated that she informed CNA #1 that Patient #1 was on a bedpan during shift change report at approximately 7:00 PM. Continued interview revealed CNA #2 stated that she returned to work on 03/12/15 at 7:00 AM and was told in report that Patient #1 was placed on a bedpan at approximately 6:30 AM. Further interview revealed that she stated she went in to feed the resident at approximately 10:00 AM and found the patient lying on his/her side, saw the red bruising on Patient #1's buttocks, and called in RN #2 and she assisted in taking pictures of the new pressure sore/injury.

Interview with RN #2 on 04/01/15, at 5:10 PM revealed she was working on the floor where Patient #1 was being treated on 03/12/15. She stated that Patient #1's primary nurse (RN #1) was providing care for another patient and she had taken over the care of Patient #1. Continued interview revealed CNA #1 notified RN #2 of Patient #1's new pressure sore/injury in the shape of a bedpan at approximately 10:00 AM on 03/12/15. RN #2 stated that she took pictures of the new injury while CNA #2 assisted her. RN #2 stated she reported the new pressure sore/injury to RN #1 when RN #1 resumed care of the patient. RN #2 stated she did not inform Physician #1 of the new pressure sore/injury. RN #2 stated she did not enter the injury into the facility's incident tracking system because Patient #1 was not her assigned patient.

Interview with RN #1 on 04/06/15 at 11:00AM revealed she was working on 03/12/15 and was assigned as Patient #1's primary care nurse. Continued interview revealed RN #1 had to assist a physician with two procedures on 03/12/15 and passed the care of her patients to RN #2. RN #1 stated when she returned to the floor RN #2 reported the new pressure sore/injury to her and she immediately informed the Unit Manager. RN #1 stated that she did not inform the primary physician of the new injury and offered no explanation on why she did not. RN #1 further stated she did not enter the injury into the facility's incident tracking system because she did not find the wound.

Interview with RN #3 revealed she was working the night shift on 03/11/15 with CNA #1. She stated Patient #1 was her patient and that she provided care to the patient. She stated she made rounds, and turned and repositioned the patient throughout the night. She stated Patient #1 was not left on a bedpan the entire night or for an extended period during the evening shift. Further interview revealed that to her knowledge CNA #1 did not place Patient #1 on a bedpan throughout the night until the morning of 03/12/15 at approximately 6:30 AM.

Interview with the Unit Manager (UM) on 04/01/15 at 4:30 PM revealed she was the Unit Manager for the third floor tower unit where Patient #1 was being cared for on 03/11/15 and 3/12/15. She stated RN #1 informed her that Patient #1 had "marks" to the buttocks area from being left on a bedpan for an extended period of time. She stated she did not think this was a significant incident and did not enter it into the internal incident log. She stated she conducted an "informal investigation" and interviewed the nursing assistants involved along with the RNs that were working when the incident occurred. She stated that she also provided an "informal" re-education to the staff regarding leaving patients on a bedpan for an extended period of time. She stated she mentioned the incident "in passing" to the Risk Manager and to the Chief Nursing Officer (CNO) but that she informed the CNO on 03/13/15 that the incident had been resolved. The Unit Manager could produce no documentation of her investigation or her re-education to the staff surrounding the incident.

Interviews with CNA #1 on 04/02/15 at 11:10 AM, CNA #2 on 04/01/15 at 5:00 PM, and RN #2 on 04/01/15 at 5:10 PM, revealed they could not recall any kind of in-service or education regarding leaving patients on a bedpan for an extended period of time.

Interview with the Risk Manager on 04/02/15 at 12:15 PM stated she heard about the incident in passing on approximately 03/12/15 but the incident was never entered into the incident tracking system as per facility policy. The Risk Manager stated the facility had a policy to track, monitor, and report all incidents. She stated that the RN or Unit Manager should have entered the incident into the system, reported the incident to the patient's primary physician and, at that point, she would have been alerted by the incident tracking system and begun an investigation into the incident. The interview further revealed the Risk Manager stated the first knowledge she had that the issue was not resolved was when state surveyors entered the facility on 04/01/15.

Interview with Physician #2 on 04/06/15 at 2:15 PM revealed that he was Patient #1's primary physician prior to the admission to Facility #1 and examined and assessed the Patient at Facility #2. Physician #2 stated he saw Patient #1 at Facility #2 the Monday after the patient was admitted to Facility #2 (six days after admission to Facility #2). Physician #2 stated that Patient #1's buttocks and coccyx looked about the same as they did prior to admission to Facility #1. He also stated he saw bruising in the shape of a bedpan that appeared to be healing. The interview further revealed at the time of the interview that Physician #2 had not been asked to participate in or be a part of any investigation by Facility #1.

Interview with the Chief Nursing Officer (CNO) on 04/02/15 at 12:15 PM revealed she had been told of the incident involving Patient #1 in passing on approximately 03/12/15 by the Unit Manager. She stated she followed up with the Unit Manager on 03/13/15 and was informed the incident was resolved. The CNO stated the facility had a policy to track, monitor, and report all incidents. She stated that the RN or Unit Manager should have entered the incident into the system, reported the incident to the patient's primary physician, and at that point, the Risk Manager would have been alerted by the incident tracking system and begun an investigation into the incident. The CNO stated the first knowledge she had that the issue was not resolved was when state surveyors entered the facility on 04/01/15. The CNO stated Facility #1 began an investigation into the incident on 04/03/15 and suspended CNA #1 and CNA #2 on 04/03/15 from direct care. Further interview revealed the CNO re-educated staff that provided care to patients that were treated on the same floor as Patient #1. The CNO stated she re-educated on wound care, abuse and neglect reporting, incident reporting, and documentation.

Based on interview, record review, review of facility policy, and review of outside facility documentation (nursing home record and outpatient clinic record) it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #1). The facility admitted Patient #1 on 02/16/15, with skin breakdown to the lower extremity. The facility identified skin breakdown/pressure areas to the resident's buttocks on 02/26/15 (ten days after admission). The facility failed to assess the skin breakdown/pressure area to the patient's buttock, failed to notify the physician and obtain treatment orders for the pressure areas, and failed to monitor the pressure areas as directed per facility policy. On 03/12/15, Patient #1 was found on a bedpan with skin breakdown in the shape of a bedpan. Direct care nursing staff reported to the Unit Manager that the resident had been left on the bedpan for an extended period of time resulting in skin breakdown to the buttock/coccyx area. The facility failed to assess/monitor the skin breakdown/pressure area per facility policy, failed to investigate the incident, and failed to contact the resident's physician of the new pressure area.

The facility failed to identify patient care needs and to provide an adequate number of Registered nurses and other staff to plan, evaluate, supervise, and participate in the nursing care of Patient #1. On 03/12/15 at approximately 7:30 AM, Registered Nurse (RN) #1 was participating in a procedure with a physician on a patient and she passed the care of her remaining patients including Patient #1 to RN #2. At that point, RN #2 was responsible for the care of eleven (11) to twelve (12) patients on that floor of the facility. During this time, Patient #1 developed wounds/pressure sores after being left on a bedpan for an extended period of time.

The failure of the facility to identify patient care needs and adequately staff the facility with Registered Nurses to provide care and to protect patients from neglect placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and is ongoing.

Refer to A0392 and A0395.

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to adequately staff the facility with Registered Nurses to provide appropriate care for one (1) of ten (10) sampled patients (Patient #1). The facility failed to identify patient care needs and to provide an adequate number of Registered Nurses and other staff (Certified Nursing Assistants) to plan, evaluate, supervise, and participate in the nursing care of Patient #1. On 03/12/15 at approximately 7:30 AM Registered Nurse (RN) #1 was participating in a procedure with a physician on a patient and she passed the care of her remaining patients including Patient #1 to RN #2. At that point, RN #2 was responsible for the care of eleven (11) to twelve (12) patients on that floor of the facility. Certified Nursing Assistant (CNA) #2 was providing care for Patient #1 on 03/12/15. CNA #2 was responsible for fourteen (14) other patients on the floor as well. As a result of the facility's failure, Patient #1 developed wounds/pressure sores after being left on a bedpan for an extended period of time.

The failure of the facility to identify and adequately staff the third floor tower unit of the facility with Registered Nurses and CNAs to provide necessary care and to protect patients from neglect placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and is ongoing.

The findings include:

Review of the facility policy titled "Assignment of Nursing Care," dated 02/06/13, revealed the facility shall staff with Registered Nurses on all shifts. Assignments of patient care will be made only by a Registered Nurse based on a patient's care needs and qualifications of nursing staff and/or applicable laws, regulations, and facility policy.

Review of the Internal Complaint Log revealed from January 2015 until April 2015 the facility logged fifteen (15) complaints from staff regarding concerns with lack of staffing on the third floor of the tower of the facility. The Unit Manager of the floor documented on each complaint that the facility "had 6:1 nursing coverage and RNs requested assistance from House Supervisor, no staff available in house to pull from to assist."

Interview with CNA #1 on 04/02/15 at 11:10 AM revealed he was working the night shift from 7:00 PM on 03/11/15 to 7:00 AM on 03/12/15. He stated he was the only CNA working that shift and was assigned to care for thirty (30) patients. The interview further revealed CNA #1 stated his job duties included turning and repositioning patients, making rounds, bathing patients, obtaining vital signs, and changing patients as needed. He stated he started taking vital signs at 3:00 AM and did not finish until approximately 6:30 AM on 03/12/15. Continued interview revealed the RNs had to assist him with providing care to the patients because he could not complete all of his duties due to the inadequate amount of staff. He stated that on the night of 03/11/15 Patient #1 was using a bedpan when he came on shift and he took the patient off of the bedpan at approximately 7:30 PM. Further interview revealed that at 6:30 AM on 03/12/15 he placed Patient #1 back on a bedpan and reported this to CNA #2 and went off shift at 7:30 AM.

Interview with CNA #2 on 04/01/15 at 5:00 PM revealed she was working the day shift (7:00 AM to 7:00 PM) on 03/11/15 and 03/12/15. She stated she was one of two CNAs working the floor on those two days. The interview further revealed her job duties included taking vital signs, handing out meal trays (breakfast, lunch, and dinner), assisting any patients that required help with eating, bathing patients, changing linens, changing patients, turning and repositioning patients, and making hourly rounds. She stated on 03/12/15 she was assigned to provide care for fifteen (15) patients. Continued interview revealed that on average approximately 50 percent of her patients were total care (patients requiring assistance with all activities of daily living). She stated at approximately 6:45 PM on 03/11/15 she placed Patient #1 on a bedpan and when she went back to check on the patient he/she stated they were not finished. She stated that she informed CNA #1 that Patient #1 was on a bedpan during shift change report at approximately 7:00 PM. She stated that she returned to work on 03/12/15 at 7:00 AM and was told in report that Patient #1 was placed on a bedpan at approximately 6:30 AM. Further interview revealed she went in to feed the resident at approximately 10:00 AM and found the patient lying on his/her side and saw red bruising on Patient #1's buttocks. CNA #1 stated she notified RN #2 and she assisted in taking pictures of the pressure sore/injury. She stated RN #1 was the assigned nurse for Patient #1 but she was unavailable and RN #2 had responsibility for RN #1's patients and her own patients during the time the injury occurred. She stated that there was not enough nursing coverage on this unit of the facility on a regular basis.

Interview with CNA #3 on 04/06/15 at 12:15 PM revealed she was working on the day of the incident and she was one of two CNAs working on the floor. She stated she was providing care for fifteen (15) patients and ten (10) of those patients required total care. Continued interview revealed that her duties included bathing patients, getting meal trays (breakfast, lunch, and dinner) for her patients, making rounds, changing patients, turning and repositioning patients, and obtaining vital signs on her patients. Further interview revealed that on top of her normal duties, the unit had a sitter with a patient and she had to provide coverage for the sitter's lunch and breaks. She stated the RNs assisted at times, but she was responsible to complete her assigned duties. She stated there was not enough staff coverage (RNs and CNAs) on this unit especially on the day of the incident but "pretty much all the time."

Interview with RN #2 on 04/01/15, at 5:10 PM revealed RN #2 was working on the floor where Patient #1 was a patient on 03/12/15. She stated RN #1 had to assist a physician with a procedure on a patient and had handed responsibility of care of her remaining patients to RN #2. Continued interview revealed at that point she had eleven (11) patients to provide care for, making the staffing ratio eleven (11) patients to one (1) RN. Further interview revealed the staffing ratio for the facility for RNs was six (6) patients to one (1) and for CNAs, fifteen (15) patients to one (1). She stated the patients on the floor of the facility were very ill and required intense care. Further interview revealed that on average 50 percent of the patients on the floor required total care. Continued interview revealed CNA #1 notified RN #2 of Patient #1's new wound in the shape of a bedpan at approximately 10:00 AM on 03/12/15. She stated that she took pictures of the new injury while CNA #2 assisted her. She stated she reported the new pressure sore/injury to RN #1. RN #2 stated she did not enter the injury into the facility's incident tracking system because Patient #1 was not her assigned patient. RN #2 further stated that this floor of the facility did not have enough staff to provide care to the patients and that inadequate staffing was the reason this incident with Patient #1 occurred.

Interview with RN #1 on 04/06/15 at 11:00 AM revealed she was working on 03/12/15 and was assigned as Patient #1's primary care nurse. Continued interview revealed RN #1 had to assist a physician with two procedures on 03/12/15 and passed the care of her patients to RN #2. She stated when she returned to the floor RN #2 reported the new pressure sore/injury to her and she immediately informed the Unit Manager. RN #1 revealed the staffing ratio usually is six (6) patients to one (1) RN, except when RNs are required to assist physicians with a procedure and the staffing ratios are outside the guidelines. Continued interview revealed RN #1 stated that floor of the facility does not have enough nursing coverage to provide care to the patients on a regular basis.

Interview with RN #4 on 04/06/15 at 12:00 PM revealed she was working the day shift on the day of the interview and she was responsible for six (6) patients and three (3) of her patients were total care. She stated the staffing ratio was supposed to be six (6) patients to one (1) RN, but that does not always happen. She stated it had been a "long standing problem" that there was not enough nursing staff to provide care for the acuity level of the patients they provided care for. Continued interview revealed staffing was the reason Patient #1 was left on a bedpan for an extended period of time and Administration was aware of the staffing issues.

Interview with the Unit Manager (UM) on 04/01/15 at 4:30 PM revealed she was the Unit Manager for the floor where Patient #1 was being cared for on 03/11/15 and 3/12/15. She stated RN #1 informed her that Patient #1 had "marks" to the buttocks area from being left on a bedpan for an extended period. She stated she did not think this was a significant incident and did not enter it into the internal incident log (facility system for reporting incidents). She stated she conducted an "informal investigation" and interviewed the nursing assistants involved along with the RNs that were working when the incident occurred. She stated that she also provided an "informal" re-education to the staff regarding leaving patients on a bedpan for an extended period of time. She stated she did mention the incident in passing to the Risk Manager and to the Chief Nursing Officer (CNO) but she informed the CNO on 03/13/15 that the incident had been resolved. The Unit Manager could produce no documentation of her investigation or her re-education to her staff surrounding the incident. Continued interview revealed that she did receive a number of complaints from staff regarding not enough staff to provide care. The Unit Manager stated it was difficult to recruit and retain staff.

Interviews with CNA #1 on 04/02/15 at 11:10 AM, CNA #2 on 04/01/15 at 5:00 PM, and RN #2 on 04/01/15, at 5:10 PM, revealed they could not recall any kind of in-service or education regarding leaving patients on a bedpan for an extended period of time.

Interview with the Chief Nursing Officer on 04/02/15 at 12:15 PM revealed she was aware there were staffing issues on this particular floor of the facility and confirmed there were staffing issues throughout the facility. Continued interview revealed that the facility was actively recruiting at this point to fill all open positions in nursing and for CNAs.

Based on interview, record review, review of facility policy, and review of outside facility documentation (nursing home record and outpatient clinic record) it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #1). The facility admitted Patient #1 on 02/16/15, with skin breakdown to the lower extremity. The facility identified skin breakdown/pressure areas to the resident's buttocks on 02/26/15 (ten days after admission). The facility failed to assess the skin breakdown/pressure area to the patient's buttocks, failed to notify the physician and obtain treatment orders for the pressure areas, and failed to monitor the pressure areas as directed per facility policy. On 03/12/15, Patient #1 was found on a bedpan with skin breakdown in the shape of a bedpan. Direct care nursing staff reported to the Unit Manager that the resident had been left on the bedpan for an extended period of time resulting in skin breakdown to the buttock/coccyx area. The facility failed to assess/monitor the skin breakdown/pressure area per facility policy, failed to investigate the incident, and failed to contact the resident's physician of the new pressure area.

The findings include:

A review of the facility policy (Skin and Wound Care) dated 02/20/07 revealed wound assessments and measurements should be done on all open wounds upon admission or when identified, when indicated by change in appearance, weekly, or upon discharge. The description of the wound should include the size (measurements), wound bed, wound edges, and surrounding skin. The policy further revealed the initial assessment includes a baseline description of the wound and the assessment process includes notification of the physician. Continued review of the policy revealed ongoing wound documentation should reflect significant clinical findings, specific wound care provided, patient progress, coordination, and communication of care with the physician. The policy revealed wound photography should be done upon admission, if pressure wound has significant changes (improves or worsens), if new pressure wound develops, and at time of discharge. Continued review of the policy revealed wound documentation should be noted on the Wound Care Form.

A review of Facility #3's (outpatient clinic) physician notes, dated 02/11/15 (four days prior to admission to the facility), revealed Patient #1 was seen by Physician #2 and had an ongoing pressure ulcer to the buttocks that had initially developed in September 2014.

A review of the medical record of Patient #1 revealed the facility admitted the patient on 02/16/15 with diagnoses including Acute Renal Failure, Sepsis secondary to diabetic ulcers in the left leg, and Diabetes Mellitus. A review of Patient #1's Adult and Pediatric Nursing History (admission assessment), dated 02/16/15, revealed the patient was assessed to have three (3) pressure areas/diabetic ulcers to the left lower extremity. A review of Patient #1's physician orders, dated 02/16/15, revealed Stage 2, Stage 3, and Stage 4 Pressure Ulcer Protocols were initiated for the patient's pressure areas to the left lower leg. The Stage 2 protocol and Stage 3 and 4 Pressure Ulcer Protocols both include the following interventions for prevention of the development of further pressure: pressure relief devices (mattress, pillows), turn and reposition of the patient, education of the patient and family on wound care and wound prevention, and an assessment of the patient's nutritional status. The protocols also include instructions to remove old dressings gently and to clean wounds with room temperature normal saline. The Stage 2 protocol dressing instructions for Patient #1 were to apply two (2) layers of skin protectant with a protective wipe and allow to dry between applications and apply a DuoDerm dressing every other day, as needed or per the physician's orders. The Stage 3 and 4 protocol dressing instructions for Patient #1 were to apply two (2) layers of skin protectant with a protective wipe and allow to dry between applications and apply Aquacel cover with DuoDerm, Telfa, or another dry dressing every day as needed or per the physician's orders.

A review of Patient #1's Patient Assessment Flow Sheet (daily assessment), dated 02/17/15 through 02/26/15, revealed no documented evidence the patient had pressure areas to the patient's buttocks.

A review of Patient #1's Wound Care Form, dated 02/26/15 at 11:00 PM, revealed the patient was assessed to have a Stage 2 pressure area to the left and right buttocks and a picture of the area was obtained. Further review of the record revealed no documented evidence of the physician being notified of the areas or of physician's orders being obtained for treatment of the areas.

A review of Patient #1's Patient Assessment Flow Sheets, dated 02/27-28/15, 03/01/15, 03/03-07/15, 03/09-10/15, 03/14-16/15, 03/19-21/15, and 03/23/15 revealed the patient had a Stage 2 pressure area to the buttocks/coccyx and/or a dressing in place on the pressure sore to the buttocks. However, the facility wound and skin policy was not implemented. The documentation in Patient #1's record did not include a description of the wound, treatment provided to the wound, and notification of the physician.

A review of Patient #1's Wound Care Form, dated 03/02/15, revealed the patient had a Stage 2 pressure area to the buttocks area and a picture of the area was obtained (four days after area identified); however, no measurements of the wound were included in the assessment. In addition, the documentation did not include improvement or decline in the wound. The next picture taken of the patient's buttock pressure sore was on 03/12/15 (ten days after 03/02/15). The Wound and Skin policy directs that pictures of pressure sores be taken on admission, weekly, with a significant change, and upon discharge.

A review of Patient #1's Patient Assessment Flow Sheet, dated 03/12/15, revealed the patient had a Stage 2 area and redness to the buttocks and a picture was obtained of the area. Although the area to the buttock was not described, observation of the picture revealed a significantly larger discolored area covering over half of the buttock area. There was no documentation of an assessment of the area or that the physician was notified.

Interview on 04/02/15 at 11:10 AM with CNA # 1 revealed the CNA had placed Patient #1 on the bedpan on 03/12/15 at around 6:00 AM. The CNA stated he checked on the patient several times between 6:00 AM and 7:00 AM to see if the patient was ready to be taken off the bedpan but the patient did not want the bedpan removed. Further interview with CNA #1 revealed the CNA gave report to CNA #2 at around 7:00 AM and informed CNA #2 that Patient #1 was still on the bedpan and would require assistance to get off the bedpan.

Interview on 04/01/15 at 5:00 PM with CNA #2 revealed she went into Patient #1's room on the morning of 03/12/15 at around 10:00 AM to feed the patient breakfast. The CNA stated she found the patient lying on the bedpan positioned toward his/her right side. CNA #2 revealed she took the patient off the bedpan and there was a "bad mark" on the patient's bottom. The CNA stated she reported the area to RN #2.

Interview on 04/01/15 at 5:10 PM with RN #2 revealed on the morning of 03/12/15, she was covering the care of Patient #1 while his/her nurse was assisting with a procedure in another patient's room. The RN stated CNA #2 reported to her that she (CNA #2) had found Patient #1 on the bedpan and the patient had markings on his/her bottom from lying on the bedpan. RN #2 said she immediately went to look at the area on Patient #1's buttock and took pictures of the area. RN #2 revealed the patient's bottom had indentions and bruising in the shape of a bedpan. According to RN #2, she reported to RN #1 that Patient #1 had been left on the bedpan too long and that that the resident had skin breakdown in the shape of the bedpan to the buttocks. The RN stated patient wounds should be documented by facility staff on the wound care sheet daily. Pictures of wounds should be taken on admission, when new wounds were identified, when a wound worsens, each week on Sunday, and at discharge. RN #2 stated when a new wound was identified an incident report should be completed related to the wound, and the physician and the Unit Manager should be notified of any new wound. The RN acknowledged she was the nurse that discharged Patient #1 from the facility and was busy and did not take pictures of the wound upon discharge.

Interview on 04/06/15 at 11:00 AM with RN #1 revealed the RN was assisting with a critical patient on the morning of 03/12/15 when Patient #1 was found on the bedpan. The interview revealed RN #1 was informed of the area (described as markings in the shape of a bedpan) to Patient #1's buttock by CNA #2 and RN #2 and was aware RN #2 took pictures of the area. RN #1 stated she informed the Unit Manager about Patient #1 being found on the bedpan and of the areas on the patient's bottom. The RN revealed Patient #1 became very ill that day and had very high temperatures and the RN frequently visualized the patient's skin when placing cooling blankets but did not remember assessing the patient's bottom. The RN stated she had failed to call the patient's physician and report the incident/injury. According to RN #1, she did not complete an incident report and did not remember documenting the incident or the skin breakdown to the patient's bottom in the medical record. The interview revealed pictures should be taken on wounds when admitted, when identified, when the wound worsens, weekly, and at discharge. Further interview revealed wounds should be documented daily on the wound care sheet.

Interview on 04/01/15 at 4:30 PM with the Unit Manager revealed she was informed by the facility staff that Patient #1 had been placed on the bedpan at change of shift and had not been removed from the bedpan until around 9:00 AM. The Unit Manager stated she was also told the bedpan had left marks on the patient's bottom. The Unit Manager stated she looked into the incident and did not feel like the marks on the patient's bottom were severe enough to indicate the patient had been left on the bedpan for an extended period of time. Continued interview revealed the Unit Manager revealed she educated all staff working at the time of the incident to be cautious about the time a patient was left on the bedpan. However, the Unit Manager failed to document the incident, an investigation of the incident, or the education of staff. The Unit Manager revealed the areas on the patient's bottom should have been described in the nurse's documentation better from the time the areas were identified. According to the Unit Manager, the patient's physician should have been notified of the incident and the areas to the patient's bottom. The Unit Manager revealed an incident report should have been also been completed.

Interviews with CNA #1 on 04/02/15 at 11:10 AM , CNA #2 on 04/01/15 at 5:00 PM, and RN #2 on 04/01/15 at 5:10 PM, revealed they could not recall any kind of in-service or education regarding leaving patients on a bedpan for an extended period of time.

Interview on 04/02/15 at 12:15 PM with the Risk Manager revealed the facility staff had not entered the incident into the incident reporting system so the incident had not been investigated by administrative staff.

A review of Facility #2's (nursing home where Patient #1 currently resides), nurse's notes, dated 03/24/15, revealed Facility #2 staff received report from the facility when Patient #1 was admitted. Review of Facility #2's nurse's notes revealed Facility #1 staff reported that Patient #1 had a Stage 2 wound to his/her coccyx in the shape of a bedpan from being left on the bedpan too long. A review of Facility #2's Admission Nursing Evaluation (admission nursing assessment), dated 03/24/15, revealed Patient #1 was assessed to have an unstageable wound to the left buttock, a Stage 3 wound to the right buttock, and an abrasion to the right upper buttock.

Interview on 04/06/15 at 12:51 PM with Facility #2's Licensed Practical Nurse (LPN #1) revealed Facility #1 called report to Facility #2 prior to Patient #1 being transferred to the facility. LPN #1 stated the Facility #1 nurse reported that Patient #1 had a Stage 2 wound to the buttocks which was caused by staff leaving the patient on the bedpan too long.

Interview on 04/06/15 at 10:35 AM with Physician #1 revealed the physician was not notified when facility staff identified the skin breakdown to the patient's buttock on 02/26/15 nor was he informed of the progress of the wounds. In addition, the physician stated he was not informed of Patient #1 being left on the bedpan for an extended period of time or of the identification of additional pressure areas to the patient's bottom.

Interview on 04/02/15 at 12:15 PM with the Chief Nursing Officer (CNO) revealed she was informed on 03/12/15, in passing, by the Unit Manager of the incident involving Patient #1. The CNO said she was told the patient was possibly left on the bedpan too long. According to the CNO, on 03/13/15 she followed up with the Unit Manager and was informed the incident was taken care of. The CNO stated she was not aware the incident had not been taken care of until state surveyors entered the facility on 04/01/15. Continued interview revealed the Unit Manager or the floor nurse should have entered the incident into the incident reporting system and the incident should have been investigated. The CNO stated the progress and description of all patient wounds should be documented daily and pictures of the wounds should be taken when identified, when they worsen, weekly, and upon discharge. The interview further revealed the physician should have been notified when the patient developed the wound initially and after the incident.

The failure of the facility to ensure a Registered Nurse supervised and/or evaluated the nursing care placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/06/15 and was ongoing.