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Based on policy and procedure review, record review, and staff interview the facility failed to ensure nursing staff provide the appropriate assessment, treatment, and evaluation for a patient in 1 of 10 medical records reviewed (Pt #1). This can potentially affect all patients receiving treatment at this facility.

Findings Include:

Review of Pt #1's MR beginning on 1/8/13 at 1:40 PM, revealed Pt #1 was admitted to the hospital on 3/8/12 for pneumonia and discharged to a sub-acute facility on 3/20/12. During Pt #1's stay at the acute care hospital, Pt #1 developed pressure ulcers to the coccyx (tailbone). Nursing assessments revealed the following documentation; on 3/16/12 at 4:24 PM the wound was measured as 2 separate wounds 1 cm x 1 cm and 0.5 cm x 0.5 cm; 3/31/12 at 2:45 PM the wound measured 3 cm x 2 cm; on 4/2/12 at 8:00 PM the wound measured 5 cm x 4 cm; 4/14/12 wound documented as increased from stage 2 to stage 3 pressure ulcer; 4/16/12 wound measured as 7 cm x 7.5 cm; 4/20/12 wound measured as 6 cm x 8 cm.

Review on 1/9/12 of The "Wound Treatment Selection Tip Sheet for RN's" last updated 9/2011, reveals the following guidelines; reassess wound treatment with each dressing change, if no improvement notify physician, measure wound every 7 days for daily dressing changes.

Per review of Pt #1's nursing documentation, No evidence was found that nursing staff measured Pt #1's pressure ulcer every 7 days (as per policy), to ensure staff monitored and provided appropriate treatment and interventions based on patient assessment. Per Pt #1's nursing assessments, 15 days elapsed between the 3/16/12 and 3/31/12 pressure ulcer wound measurement, and 14 days elapsed between the 4/2/12 and 4/16/12 pressure ulcer wound measurement.

Review on 1/9/13 of the facility "Wound Treatment Selection Tip Sheet" last updated 8/2011 reveals the following: All open wounds require cleansing and surrounding skin protection; Select a method for wound cleansing, surrounding skin protection, and cover dressing. Consult the physician or a CWOCN (certified wound, ostomy, and continence nurse) if needed. Types of wound cleansing listed include normal saline irrigation or wound cleanser spray (Carra Klenze); types of skin protection listed include skin sealant, incontinent barrier cream, or tape to protective barrier wafer; types of cover dressings listed include Silicone dressing, Granulex, Hydrogel, Transparent dressing, Hydrocolloid Dressing, and Hydrofiber.

Review of Pt #1's nursing assessments dated 3/20/12 to 3/29/12 reveals documentation that Pt #1's stage 2 pressure ulcer was "open to air", this is documented under coccyx "Dressing" for 9 days, until Granulex ordered by physician on 3/29/12 at 9:00 PM. No evidence in Pt #1's MR of staff providing wound cleansing, skin protection, or cover dressing as per policy. This deficient practice can lead to potential contaminates entering the uncovered open wound.

Per interview on 1/9/12 beginning at 12:30 PM with RN G (CWOCN), RN G was not consulted on Pt #1's coccyx pressure ulcer wound, despite the wound increasing in size, going from a stage 2 to stage 3 pressure ulcer, and not responding to current nursing interventions.

Per review of Pt #1's incident report dated 3/22/12, Pt #1 had an unwitnessed fall on 3/22/12 at 10:15 am. Per Fall Prevention Policy and Procedure last reviewed 8/2011, if patient falls nursing staff is to assess for airway, breathing, circulation, mental status, neurological check (if fall was unwitnessed), glycemic status, physical findings, and cervical spine tenderness (policy does not specify assessment timeframe or frequency). Review of Pt #1's nursing assessments on 3/22/12, shows no evidence of a nursing assessment of Pt #1 immediately post fall. Nursing assessment not documented until 5:10 PM, 6 hours and 55 minutes after Pt #1 fell. This is confirmed with Dir A and RN D on 1/9/13 beginning at 3:45 PM. Per Interview with Dir A and RN D on 1/9/13 beginning at 3:45 PM, the facility does not have a specific protocol for nursing staff to follow which directs the frequency and length of monitoring patients post unwitnessed and witnessed falls which could potentially involve a head and/or neck injury.

Based on policy and procedures, record review, and staff interview the facility failed to ensure nursing care plans are individualized and specific to patient needs and updated and revised in response to patient assessment in 10 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,9,10). This can potentially effect all patients receiving treatment at this facility.


Facility Policy and Procedure: Interdisciplinary Documentation; Last reviewed August 2011 states the following:
1. Expected outcomes are documented as measurable goals and provide direction for continuity of care.
2. Interventions are accurate, timely, cost effective, and are performed and documented by appropriate skilled and qualified caregivers to reflect standardized best practice.
3. Patient progress is measured and documented as progress toward individualized expected outcomes.

Findings Include:

Review of Pt #1's MR beginning on 1/8/13 at 1:40 PM, revealed Pt #1 was admitted to the hospital on 3/8/12 for Pneumonia and discharged to a sub-acute facility on 3/20/12. During Pt #1's stay at the acute care hospital, Pt #1 developed pressure ulcers to the tail bone area (coccyx). Nursing assessments revealed the following documentation; on 3/16/12 at 4:24 PM the wound was measured as 2 separate wounds 1 cm x 1 cm and 0.5 cm x 0.5 cm; 3/31/12 at 2:45 PM the wound measured 3 cm x 2 cm; on 4/2/12 at 8:00 PM the wound measured 5 cm x 4 cm; 4/14/12 wound increased from stage 2 to stage 3 pressure ulcer; 4/16/12 wound measured as 7 cm x 7.5 cm; 4/20/12 wound measured as 6 cm x 8 cm.

Review of Pt #1's Integumentary (skin) interdisciplinary plan of care dated 3/14/12 to 4/20/12, reveals goals are listed as "no new impairment" and "evidence of healing" these goals are not measurable and individualized to specific patient needs. The goals are not updated or revised during Pt #1's admission to reflect worsening wound assessment. "Progress to goal" related to evidence of healing is documented in skin care plan despite Pt #1's worsening pressure ulcer. Interventions listed in Pt #1's skin plan of care are not individualized and specific to Pt #1's needs, interventions are not updated and revised to reflect Pt # 1's worsening wound assessment, due to current interventions being ineffective. Interventions listed in plan of care are not consistently documented in Pt #1's MR as being completed and evaluated for effectiveness. Per review of incident report dated 3/22/2012 at 10:15 am, Pt #1 fell. Pt #1's Safety Plan of Care is not revised and updated to reflect this incident, goal for "free of fall" is documented as "progress to goal", despite goal not being met.

Review on 1/9/12 beginning at 4:20 PM of Pt #2,3,4,5,6,8,9,10 Interdisciplinary Nursing Plan of Care, reveals care plans do not contain measurable and individualized goals and interventions specific to patient needs and nurse assessments.

Per interview on 1/9/12 with Dir A during MR review , staff pick patient interventions from a pull down list in the electronic MR.

The above finding were confirmed at the time of MR review during interview with Dir A, Dir C, and RN D.

Based on policy and procedure, record review, and staff interview the facility failed to ensure staff document all interventions and patient progress in the medical record in 1 of 10 MR's reviewed (Pt #1). This can potentially affect all patients receiving treatment at this facility.


Findings include:

Review of Pt #1's MR beginning on 1/8/13 at 1:40 PM, revealed Pt #1 was admitted to the hospital on 3/8/12 for pneumonia and discharged to a sub-acute facility on 3/20/12. During Pt #1's stay at the acute care hospital, Pt #1 developed pressure ulcers to the tail bone area (coccyx). Nursing assessments revealed the following documentation; on 3/16/12 at 4:24 PM the wound was measured as 2 separate wounds 1 cm x 1 cm and 0.5 cm x 0.5 cm; 3/31/12 at 2:45 PM the wound measured 3 cm x 2 cm; on 4/2/12 at 8:00 PM the wound measured 5 cm x 4 cm; 4/14/12 wound increased from stage 2 to stage 3 pressure ulcer; 4/16/12 wound measured as 7 cm x 7.5 cm; 4/20/12 wound measured as 6 cm x 8 cm.

Review on 1/9/12 of The "Wound Treatment Selection Tip Sheet for RN's" last updated 9/2011, reveals the following guidelines; reassess wound treatment with each dressing change, if no improvement notify physician, measure wound every 7 days for daily dressing changes.

Pt #1's pressure ulcer wound measurement was not documented every 7 days as per policy, 15 days elapsed between the 3/16/12 and 3/31/12 wound measurement, and 14 days elapsed between the 4/2/12 and 4/16/12 wound measurement.

Per Pt #1's MR nursing staff documented "skin care management" as an intervention under the Integumentary(skin) Plan of Care. Interview with Dir A and RN D on 1/9/2012 beginning at 12:30 PM revealed the skin care management protocol includes turning patients every 2 hours. The only documentation of staff repositioning Pt #1 is in the "Routine Care" category, nursing staff mark "met" in the "personal hygiene" box once per shift. Dir A and RN D confirmed there is no specific documentation in the medical record of what time the patient was repositioned, who repositioned the patient, what side the patient was turned on, and how the patient tolerated being turned.

Per review of Pt #1's nursing assessments, skin interventions documented do not specify which intervention was done for which area of the body. Interventions listed are generic and are not specific. Integumentary (skin) nursing assessment on 3/16/12 at 9:27 am reveals Pt #1 has abnormal skin assessment for hands, coccyx, lip, and mouth. Interventions listed are as follows: "extremity elevated" and "pressure relief". This documentation does not indicate which extremity was elevated or where and what type of pressure relief was provided to
Pt #1. Per the Wound Treatment Selection Tip Sheet for RN's last updated 9/2011, all open wounds require cleansing, surrounding skin protection, and a cover dressing, multiple options are listed for the RN to choose based upon wound assessment. Review of Pt #1's nursing assessments reveals staff did not consistently document these specific interventions as it relates to the type of treatment provided for Pt #1's worsening pressure ulcer.

Per review of Pt #1's incident report dated 3/22/12, Pt #1 had an unwitnessed fall on 3/22/12 at 10:15 am. Per Fall Prevention Policy and Procedure last reviewed 8/2011, if patient falls nursing staff is to assess for airway, breathing, circulation, mental status, neurological check (if fall was unwitnessed), glycemic status, physical findings, and cervical spine tenderness; policy does not specify assessment timeframe or frequency. Per review of Pt #1's nursing assessments on 3/22/12, no documentation of the above nursing assessments are noted until 5:10 PM, 6 hours and 55 minutes after Pt #1 fell. This is confirmed with Dir A and RN D on 1/9/13 beginning at 3:45 PM. Per Interview with Dir A and RN D on 1/9/13 beginning at 3:45 PM, the facility does not have a specific protocol for nursing staff to follow which directs the frequency and length of monitoring patients post unwitnessed and witnessed falls which could potentially involve a head and/or neck injury.

Per review on 1/8/12 beginning at 1:40 PM, of Physician Progress notes from 3/8/12 to 4/11/12, the Integumentary (skin) assessment documented the following, "Skin Intact", and on 4/5/12 "no pressure ulcers" is documented in the physician progress note. This documentation is inconsistent with the nurses assessments starting on 3/16/12 of Pt #1 having a stage 2 pressure ulcer to the coccyx (tailbone). On 3/29/12 at 9:00 PM, Physician order written for Granulex spray to apply to sacral pressure ulcer, no documentation in physician progress notes acknowledging or assessing Pt #1's pressure ulcer until 4/12/12. Physician Progress notes on 4/13/12 and 4/14/12 still indicated "skin intact". This is confirmed at time of record review during interview with Dir A and RN D.