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Based on observation and interview the facility failed to ensure that there were enough nurses to ensure someone would for 1 (#3) of 5 patients, changed his/her dressing to a pressure ulcer according to the physician's order.

Findings:

Record review revealed that patient #3 has a pressure ulcer on the buttocks. Further record review revealed an open area with a red base on admission to the facility and there was a physician order dated 10/02/10 for the application of a dressing to left buttock every other day (QOD). Preventive measure were put into place which included turning and repositioning.

Interview was conducted with the Licensed Practical Nurse #1 (LPN ) assigned to patient #3 on 10/18/10 at 12:45 PM. During this meeting it was revealed that on 10/09/10, at that time she confirmed with patient #3's daughter , that the pressure ulcer bandage to patient #3's buttocks was dated as applied and changed on 10/03/10. Which indicated that it had not been changed as the physician had ordered of every other day (QOD).

Interview on 10/18/10 at 1:30 PM with the wound care nurse, Registered Nurse (RN#1), she confirmed that there was no documentation that this wound dressing to patient #3's left buttock was changed between 10/03/10 and 10/09/10. Therefore, nursing staff had not followed physician orders to change the dressing every other day for 6 days.

Telephone interview with patient #3's daughter at 8:45 PM, confirmed that they had reported to the staff that patient #3 did not have his/her dressing changed according to the physician's orders. The dressing was covering patient #3's pressure ulcer to his/her buttocks. The daughter also stated that they had spoken with patient #3's nurse ( Licensed Practical Nurse #1) on 10/09/2010 and that she had confirmed that the dressing to patient #3's buttocks was dated 10/03/2010, which indicated that this dressing had not been changed for six (6) days.