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Based on record review, policy review and staff interview it was determined the facility failed to ensure the registered nurse supervised and evaluated nursing care related to skin care assessments for 2 (#1, # ) of 30 sampled patients. This practice does not ensure nursing goals are met and may lead to an increased hospitalization.

Finding include:

1. Patient #1 was admitted to the medical surgical unit on 12/13/12. Review of the initial nursing skin assessment dated 12/13/12 at 11:15 a.m. revealed a pressure ulcer to the coccyx area. The documentation noted skin abnormality to the coccyx and right buttocks. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/13/12 at 11:50 p.m., 12/14/12 at 10.58 a.m. and 9:37 p.m., 2/15/12 at 8:01 a.m. and 8:25 p.m. revealed the same information. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/16/12 at 2:34 p.m. revealed an open area on the coccyx, Duoderm had been applied on 12/14/12 and pictures were obtained. The documentation noted a pressure ulcer on the coccyx and abnormalities of the right buttock and coccyx. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/16/12 at 9:55 p.m. showed a pressure ulcer on the coccyx and skin abnormalities on the right buttocks and coccyx. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/17/12 at 1:33 p.m. revealed the old wound site appeared to be opened. The documentation noted pressure ulcer on the coccyx and skin abnormalities on the right buttocks and coccyx. There was no description or size of the abnormalities or pressure ulcer documented. Review of Wound Care Nurse (WCN) documentation dated 12/18/12, no time, revealed a 1x1x0.2 centimeters wound. The WCN indicated to use Duoderm and to change every three days. The WCN stated to refer to the wound care center upon discharge

Interview with the Licensed Practical Nurse caring for the patient on 12/17/12 at approximately 11:20 a.m. revealed on 12/14/12 the coccyx area was red and Duoderm was applied. On 12/16/12 the area was noted to be opened and on the mid back was a two shade bruised like area. She stated the physician was notified and a wound care nurse consult was ordered. The LPN stated the area remained open to air.

Review of policy and procedure "Skin Integrity Protocol and Prevention Guidelines #N3-07 last revised 3/12 revealed to assess, measure and document all wounds on admission and identification. The policy indicated for patients at risk, the patient should be turned every two hours, there should be a position turn clock at the head of the bed, and to use positioning devices.

Patient observation on 12/17/12 at approximately 10:40 a.m. revealed the patient was on the back and no evidence of a position turn clock or positioning devices.

Interview and record review with the Director of the Medical Surgical Unit on 12/17/12 confirmed the findings.

2. A review of patient #27 ' s clinical record revealed the patient was admitted to the facility on 12/17/12 with a diagnosis of syncope. The patients past medical history were diabetes, hypertension, cardiac disease, pacemaker and high cholesterol. Further review of the patient ' s clinical record nursing assessments revealed an assessment was completed on 12/18/12 at 10:21. There were no further assessments documented at the time of the chart review on 12/19/12 at 9:30 am.
An interview with the Nursing Units Nurse Manager conducted on 12/19/12 at approximately 10:00 am, confirmed there were no other assessments documented in the record. When questioned on how often assessments are completed, the nurse manager stated depending on the patient condition if stable than every shift (every 12 hours).

Based on record review and staff interview it was determined the facility failed to administer medications in accordance with physician orders for one (#13) of thirty patients sampled. This practice does ensure safe and effective medication therapy.

Findings include:

1. Patient #13's physician order dated 12/6/12 at 6:28 p.m. instructed for Vancomycin 1 gram intravenously (IV) every twelve hours. At 9:00 p.m. the Vancomycin was changed to 1 gram every eight hours. The order indicated for a trough level to be obtained on 12/8/12 at 5:30 a.m. and the pharmacist was to dose.
Review of the Medication Administration Record (MAR) dated 12/6/12 noted the medication was administered at 7:20 p.m. Interview with the Director of the Medical Surgical Unit on 12/18/12 during the electronic record review revealed revealed the pharmacy timed the medication to be administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m.
Review of the MAR noted on 12/7/12 the Vancomycin was administered at 5:02 a.m. and midnight. Review of the nursing documentation revealed no evidence of why the 6:00 p.m. dose was not administered or why the 10:00 p.m. dose was given late.
Review of the MAR dated 12/8/12 revealed the Vancomycin was administered at 2:54 p.m. and 9:35 p.m. There was no documentation as to why the morning dose was not administered. Review of the ordered trough level showed a level of 7. It could not be determine if the level was accurate since the medication had not been administered as ordered on 12/7/12 or 12/8/12.
Review of pharmacy/physician order dated 12/8/12 at 3:00 p.m. revealed the level indicated it was not a trough, for the Vancomycin to be administered as ordered and to repeat the level on 12/9/12 at 1:30 p.m.
Review of laboratory results revealed the trough was 13.4. Review of pharmacy/physician orders dated 12/9/12 at 3:20 p.m. revealed to increase the dose to 1.25 gram every eight hours.
Interview with the Director of the Medical Surgical Unit on 12/18/12 during the electronic record reviewed confirmed the above findings.
2. Patient #13's physician orders dated 12/6/12 instructed for Lisinopril/HCTZ (blood pressure medication) to be administered daily. Review of the MAR dated 12/7/12 revealed the medication was scheduled for 9:00 a.m. The MAR noted the medication was held at 6:13 p.m. Review of nursing documentation revealed the medication was held at 6:13 p.m. due to a low blood pressure. There was no evidence of what the blood pressure was or why it was not given at 9:00 a.m. There was no evidence of the physician being notified. There was no evidence of parameters given by the physician to hold the medication. Review of the MAR dated 12/9/12 revealed the medication was held for a low pressure. There was no evidence of what the blood pressure was or if the physician was notified.
Interview with the Director of the Medical Surgical Unit on 12/18/12 during the electronic record reviewed confirmed the above findings.

Based on record review, policy review and staff interview it was determined the facility failed to reassess a patient's discharge plan when dressing changes were ordered on discharge for 1 (#14) of 30 sampled patients. This practice does not ensure a safe discharge and may lead to an unnecessary readmission.

Findings include:

1. Patient #14 was admitted for an abdominal procedure on 10/8/12. Review of physician orders dated 10/12/12 at 12:25 p.m. instructed for wet to dry dressings every 12 hours to the midline abdominal wound. Nursing documentation noted the dressing was changed on 10/12/12 at 8:53 p.m. Nursing documentation dated 10/13/12 at 8:45 a.m. revealed a wet to dry dressing with packing was performed.

Review of the Patient Discharge Summary revealed the patient was discharged home on 10/13/12 at 12:30 p.m. There was no evidence of the wound care to be continued at home, if the patient was able to perform the wound care, or if the patient was assessed for post discharge wound care needs.