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Based on interviews, medical record review, and policy review the facility failed to ensure treatment was provided to aid in healing and prevent the worsening of a pressure wound upon admission, and failed to ensure the development of a plan of care for a pressure ulcer for 1 of 3 sampled patients, Patient #1.

Findings:

Review of the medical record for Patient #1 showed an admission of 8/3/2018 - 8/6/2018 with a diagnoses of Sepsis, productive cough, shortness of breath, exacerbation of COPD (Chronic Obstructive Pulmonary Disease), Pneumonia and a bedsore.

Review of the RN (Registered Nurse) admission nursing assessment dated 8/3/2018 revealed under general information: Chief complaint: was at Home experiencing shortness of breath 1 week with productive cough. Patient has home oxygen with history of partial right lobotomy and necrosis of jaw Patient has a bedsore.

Review of the physician's order sheets dated from 8/3/2018 through 8/6/2018 did not reveal any treatment order for the bedsore that was identified by an RN during the admission process.

During an interview on 11/13/18 at 3:52 PM, with Staff C, Risk Manager she stated and confirmed there was no wound care team consult, and confirmed there were no orders for the care of the bedsore for Patient #1.

During an interview on 11/13/18 at 4:13 PM, with Staff A RN (Registered Nurse) Risk Management she stated and confirmed there were no orders for wound care treatment of the bed sore for Patient #1, and there was no plan of care for this patient during this admission period.

Review of facility's policy titled "Pressure Injury Prevention" showed early identification and prevention measures include if skin breakdown is identified, physician must be identified. Interdisciplinary plan of care for skin integrity to be implemented upon identification of skin integrity issues or if patient is identified as a high risk for skin breakdown. If skin breakdown is identified, decubitus ulcer patient education should be added to the patient's education within the discharge documentation that is provided to patient at discharge. The Braden scale is a reliable instrument used to assess a patient's risk of developing pressure injuries.

Review of Pressure Injury Prevention Education Huddle showed every patient on admission to facility and on transfer within the facility to remove any dressing that is present on admission. Review of the huddle showed 4 eyes (2 staff check the patient) method for skin assessment is to be performed as soon as possible following decision to admit to the facility. The pressure injury huddle follows the same principles as the policy above.