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Based on interview, record and policy review, the facility failed to:
-Provide pressure ulcer care and treatment to patients, which resulted in the development pressure ulcers.
-Ensure patients with pressure ulcers did not develop additional ulcers and/or patients did not have further deterioration of pressure ulcers.
-Consult the wound nurse when patients experienced a change in skin condition.
-Document the physician had been notified when a patient experienced a change in skin condition and developed several opened areas on the coccyx.
-Notify the physician when opened areas did not respond to current treatment and the areas deteriorated.
-Document patients' pressure ulcer measurements on admission, or when areas first developed, weekly or at discharge.
-Clarify medications ordered with dosage questions with the physician before administering the medications to patients.
-Ensure staff contacted the physician before they wrote a verbal order to change a medication dose and administered the medication without the physician's approval for the dose change.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.23 Nursing Services.







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Based on interview, record review and policy review, the facility failed to ensure staff assessed, documented and consulted the wound nurse for patients with pressure ulcers or wounds and failed to notify the physician when pressure ulcers worsened or did not improve for three (#25, #26 and #27) of five current patients and two (#1 and #20) of three discharged patients reviewed for pressure ulcers. Pressure sores, also called pressure ulcers, are injuries to skin and underlying tissues that result from prolonged pressure on the skin. The facility census was 51.

Findings included:

1. Record review of the facility's policy titled, "Pressure Ulcer Prevention and Wound Care" revised 06/12, showed the following direction:
-Skin Assessment, Consult and Documentation: The Registered Nurse (RN) shall assess the patient for skin integrity risk factors on admission utilizing the Braden Scale (an assessment tool used for predicting the risk of pressure ulcers) and the skin assessment (which includes pressure ulcer risk assessment and wound assessment) and will consult Wound Ostomy Nursing if indicated. This initial skin assessment shall be documented in the nursing assessment.
-Assessing High Risk Patients: The RN/LPN (Licensed Practical Nurse) shall assess patients for alteration in skin integrity and circulatory impairment each shift.
A. Assess HOT SPOTS (heels, occiput [back portion of the head], toes, sacrum [large bone at the base of the spine], posterior buttocks, over bony prominence's, thoracic spine, scapula [shoulder blade], ears and between knees).
B. Document assessment and report significant findings to the physician (redness, irritation, swelling, tenderness, actual skin breakdown, ect.).
C. When Braden score found to be 12 or less, implement standing order for Pressure ulcer prevention and wound care.
D. RN's and LPN's shall consult wound nurse for newly identified alterations in skin integrity, recommendations, therapy, and management.
General Skin Care Guidelines:
-RN's and LPN's shall consult wound nurse for newly identified alterations in skin integrity, recommendations, therapy, and management.
General Pressure Ulcer Management Guidelines:
-The RN shall assess every patient on admission and a consult for the wound nurse will be made if the patient is high risk, or has an existing ulcer present. During each assessment, any new ulcers identified will result in a Wound Ostomy Nurse consult.
Dressing Changes and Assessment
-During dressing changes the nurse shall assess and document the following:
-Location of the pressure ulcer(s)
-Size (length, width, tunneling, undermining, wound bed)
-Color, odor, moisture, appearance of skin around the ulcer
-Stage of the wound (using the following table)
-Drainage
-Dressing type
-Wound Vac
-Pain

2. Record review of current Patient #25's History and Physical (H&P) showed the 87 year old patient was admitted to the facility on 08/17/12 with chest pain. The current medical problems were left lower lobe pneumonia, anemia, critical aortic stenosis (aortic valve narrows, which prevents the valve from opening fully, which obstructs blood flow from the heart into the aorta and to the rest of the body), compression fracture of the 12th vertebra, rib fracture, Chronic Obstructive Pulmonary Disease (airways become narrow which limits the flow of air to and from the lungs frequently causing shortness of breath), Macular degeneration (loss of vision) and dementia.

Record review of the skin assessment dated 08/18/12 showed a Stage II pressure ulcer (a shallow open ulcer with a red pink wound bed, without dead tissue in the center) on right buttock with no further description or measurements until 08/22/12 when a measurement was documented.

Record review showed no wound nurse consult, assessment or treatment as prescribed by the wound policy.

3. Record review of Patient #26's skin assessment dated 08/20/12 showed the patient had an ulceration at the seven o'clock position next to his urostomy (an artificial opening for the drainage of urine) stoma.

Record review of skin assessment dated during his admission showed no wound nurse consult or assessment as prescribed by the wound policy.

4. Record review of Patient #27's skin assessment dated 08/13/12 showed the patient was admitted to the facility on 08/13/12 with a Stage I pressure ulcer at the buttocks/coccyx with wound site and measurements documented.

Record review showed the skin assessment dated 08/14/12 showed changes to the amount of drainage (from none on 08/13/12 to scant) and an additional Stage I pressure ulcer at the right elbow. No consult for the wound nurse was found in the documentation.

Record review of the discharge instructions to the patient and the documented communication to the home health agency did not address the pressure ulcer or treatment.

5. During an interview on 08/22/12 at 10:00 AM Staff V, Wound Nurse, stated that all wounds were to be assessed at admission, weekly and at discharge with measurements and documentation of location, size, color odor, stage drainage and dressing type. She stated that consults were to be made if a wound was greater than a Stage II or not improving.

6. During an interview on 08/22/12 at 2:30 PM Staff R, Registered Nurse (RN), stated that the pressure ulcer policy was to assess the wound every shift and document the findings on the wound assessment. She stated that the wound nurse was to be consulted when a pressure ulcer was a Stage III or greater. She stated that the nurses on the floor did not take pictures of the sores; only the wound nurse did.

7. Record review of discharged Patient #1's ICU admission assessment dated 06/27/12 showed staff documented the following:
-Potential Problems: No pressure ulcers.
-Skin Assessment: Coccyx (tailbone) is red but blanches (becomes white).
-Pressure Ulcer Risk Assessment: Coccyx/gluteal fold (fold of the buttock) no problem.

8. Record review of the patient's Skin Assessments from 06/27/12 through 07/11/12 showed staff:
-Documented the patient did not have any skin issues or breakdown when she was admitted to the ICU on 06/27/12.
-Recorded varying descriptions of the patient's two areas of altered skin on her coccyx that ranged from non-stageable (depth unknown) due to eschar (a scab or dead tissue that falls off healthy skin), opened, pea sized, quarter sized, dime sized to Stage II (partial-thickness skin loss).
-Recorded two measurements of the patient's altered skin:
-On 07/01/12 the patient had one un-stageable wound on her coccyx that was open and measured 9 cm x 5.8 cm (centimeters, a length of measurement; one centimeter equals 12/32 inches) with a center area measuring 1.5 cm x 1.5 cm.
-On 07/03/12 the patient had two areas on her coccyx. One area measured 1.5 cm x 2 cm and the second area measured 4 cm x 2.5 cm.

Staff did not follow the facility's policy "Pressure Ulcer Prevention and Wound Care" revised 06/12 when they failed to do the following:
-Consult the wound nurse when the patient experienced a change in skin condition and developed several opened areas on her coccyx.
-Notify the patient's physician when she experienced a change in skin condition and developed several opened areas on her coccyx.

9. Record review of the patient's Progress Note dated 07/07/12 showed the physician dictated the following information:
The patient is feeling well today. She says that the main problem she has is her coccyx is sore from laying on it and complaining of pain. Apparently she has a decubitus (pressure) ulcer there which is primarily covered by a black eschar at this point. She is getting topical treatment for it.

Record review of the patient's Physician Orders dated 07/07/12 at 11:03 AM, showed the physician wrote an order for DuoDerm (a skin dressing for the treatment of areas of the skin which are healing slowly) to sacrum (large triangular bone at the base of the spine) at all times.

This is the first documentation the physician made regarding the patient's pressure ulcer on her coccyx. The patient first developed the pressure ulcer on 06/28/12 and this notation from the physician is 10 days after she first developed the opened areas.

10. Record review of SHARED (a nurse to nurse report system) for Patient #20 showed the 90 year old patient was admitted on 05/21/12 for pain and severe deconditioning due to no activity with no skin breakdown.

11. Record review of the Wound Assessment dated 05/21/12 showed the patient had a Stage I pressure ulcer at the coccyx which was blanchable Erythemia (reddened area of the skin that temporarily turns white or pale when pressure is applied with a fingertip) with pillows for comfort and support and repositioning every one to two hours and Sensicare (a protective barrier cream) to the area.

Record review of the Wound Assessment dated 05/22/12 showed the patient had a slightly reddened coccyx with frequent repositioning and barrier cream applied to the area. The Pressure Ulcer Risk Assessment documented no problems noted.

Record review of the Wound Assessment dated 05/23/12 showed the patient had an area at the coccyx which was a purple or maroon area of discolored intact skin with barrier cream applied prn (as needed).

Record review of the Wound Assessment dated 05/24/12 showed the patient had no problems with Pressure Ulcer Risk.

12. Record review of the Skin Assessments dated 05/21/2012 - 05/24/2012 showed no consult to the wound nurse.

13. Record review of the Hospital to Long-Term Care Handoff Communication dated 05/24/12 showed the patient had intact skin with no mention of the Stage I pressure ulcer at the coccyx.

14. Record review of the Physician's Discharge Summary showed the patient had a sacral ulceration (a pressure ulcer at the end of the spine).

15. During an interview on 08/22/12 at 10:10 AM, Staff V, Registered Nurse (RN), Wound Care Nurse, stated that:
-She provided a class during orientation related to pressure ulcers that included how to stage and measure wounds, and how wounds heal. After orientation the unit educators provide annual training.
-She does not assess patients with Stage I or Stage II pressure ulcers unless staff ask her for a consultation.
-Staff would contact her for consultation for patients with anything greater than a Stage II pressure ulcer.
-She expected staff to measure pressure ulcers on admission, weekly and at discharge.
-She performed chart audits for documentation and reported any concerns to the unit educator.

16. During an interview on 08/22/12 at 10:10 AM Staff W, RN, Med-Surg Unit I Educator, stated that staff on the unit had received education and training on the following:
-How to measure pressure ulcers.
-To measure pressure ulcers on admission, weekly, and at discharge.
-To mark on the body pictures where the pressure ulcers were located.
-To utilize the turning team and make hourly rounds.

17. During an interview on 08/22/12 at 2:30 PM, Staff Q, RN stated that she would consult the wound nurse on admission if a patient is admitted with any stage of pressure ulcer. Staff Q stated that pressure ulcers are to be measured during admission and once a shift unless the physician ordered something different. Staff Q stated that she would notify the physician with any changes in a patient's skin or pressure ulcers and if the current treatment did not improve the skin or pressure ulcers.




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Based on observations, interviews and policy reviews the facility failed to ensure staff administered medications in a safe manner and according to physician orders for three (#3, #24, #16) of ten patients observed during medication administration pass. The facility census was 51.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration Record, Use of" revised 08/11, showed the following direction:
-All medication orders are checked for accuracy by a licensed nurse and verified for accuracy in nursing documentation system.
-All discrepancies are thoroughly investigated and resolved by the nurse. This includes reviewing the original order and checking the eMAR (electronic medication administration record). Any discrepancy found is documented on the eMAR Reconciliation Form and faxed to the Pharmacy. Pharmacy will reconcile and make corrections, when appropriate.

2. Observation on 08/21/12 at 8:50 AM, showed Staff H, Registered Nurse (RN), administered medications to Patient #3. Staff H handed the patient a medication cup that contained 11 pills. The patient lifted the medication cup up to his mouth to take the contents when a small white pill fell out of the medication cup and landed on the floor. Staff H picked the pill up off the floor and asked the patient if he wanted a different pill or did he want to take the pill that landed on the floor. The patient stated he would take the pill that landed on the floor. Staff H picked up the pill and took a paper towel and wiped the pill off, then gave it to the patient. The patient took the pill and put it into his mouth and swallowed it.

The floor potentially could be contaminated with bacteria or viruses. Administering medication that came in contact with the floor increased the potential risk for the patient to develop infection from bacteria or viruses.

3. During an interview on 08/22/12 at 10:45 PM, Staff N, Director of Pharmacy stated that he did not expect staff to administer medications, for example pills, to patients after the medication had fallen on the floor.

4. During an interview on 08/22/12 at 12:00 PM, Staff H, RN stated that if a pill is dropped on the floor she asks the patient if they want a different pill. She stated that if the patient states they are fine taking the dropped pill or the patient states they drop their pills at home all the time and take them, she gives the dropped pill to the patient to take. Staff H stated that if a patient requests a different pill she would give them a different one. Staff H stated that she has administered dropped pills that have fallen on the floor in the past if it is what the patient wanted. Staff H stated that she will do whatever the patient requests. Staff H stated "I guess I should not have administered medications that have dropped on the floor".

5. Observation on 08/21/12 at 9:00 AM, showed Staff I, RN, was preparing to administer Alphagan 0.2% (medication to treat open-angle glaucoma or ocular high pressure inside the eye) eye drops into Patient #24's eyes. Staff I informed the patient she had his eye medication and needed to administer two eye drops into each eye. The patient stated he did not use two drops only one. Staff I informed the patient the order instructed her to instill two drops of the medication into both eyes. The patient stated he meant to inform staff he only used one eye drop. Staff I then administered one eye drop into each eye.

Staff I did not clarify the medication dose with the patient's physician before she administered the medication. Staff I did not follow the facility policy related to a medication discrepancy.

6. Review of the patient's Home Medication List dated 08/21/12 at 3:41 AM, showed the physician ordered on admission for the patient to continue his home medication Alphagan ophthalmic 2 (two) drops BID (two times a day).

7. Record review of the patient's medication administration record (MAR) dated 08/21/12 at 9:03 AM, showed Staff I documented she administered two drops of Alphagan to each eye.

8. During an interview on 08/21/12 at 9:25 AM, Staff D, RN, Director of Med-Surg I Unit, stated that she expected staff to clarify orders when there is a question about the order, for example, if a patient states they take a different dose than what the physician ordered. Staff D stated that she expected staff to clarify the order in question before administering the medication.

9. During an interview on 08/22/12 at 10:45 AM, Staff N stated that Staff I should have held the eye drops until she received clarification from the physician. Staff N stated that he expected staff to follow physician orders as written and if staff have a concern or question they need to notify the physician and receive clarification prior to administration of the medication.

10. During a telephone interview on 08/27/12 at 10:45 AM, Staff I stated that when a patient reports a different medication dose than what is documented on the MAR she calls the physician to clarify the medication order before administering the medication. Staff I stated that after clarification has been obtained from the physician she notifies the pharmacy so the clarified order will be reflected on the MAR. Staff I stated that she administered one eye drop to each eye for Patient #24 before she clarified the order with the patient's physician. Staff I stated that the documentation on the MAR did not reflect that she only administered one drop.

11. During a telephone interview on 08/27/12 at 10:47 AM, Staff A, RN, Accreditation and Licensing, stated that she expected staff to follow the facility's policies and procedures before they administered a medication dose in question.

12. Review of the facility policy titled, "Orders, Standards for Patient Care" revised 07/20/12 showed clarification or corrections of orders should be rewritten. The original order should never be altered.

13. Observation on 08/21/12 at 12:15 PM showed Staff H, RN, offered Tadalafil (a medication given for pulmonary arterial hypertension) 1 and ? tablets (tabs) to Patient #16. Patient #16 responded that he took one tab and not 1 and ?. Staff H then left the patient's room and was observed checking the dosage in the eMAR. Staff H then used the phone. She returned to the patient's room where she administered 1 tablet.

14. During an interview at the time of the observation, Staff H stated that she clarified the dosage with the patient. She stated this was a medication the facility pharmacy did not carry and the pharmacy was dispensing the medication the patient had brought from home.

15. During an interview on 08/21/22 at 1:30 PM Staff W, Pharmacist, stated that a nurse had called the pharmacy to ask what the dosage instructions were on the bottle of Tadalafil for Patient #16. Staff W stated that she told the nurse that the label on the medication bottle was 20 mg and 1 tab.

16. Record review of the Medication Reconciliation/Orders dated 08/20/12 showed that the medication Tadalafil was ordered by the physician as 1 and ? tabs of 20 mg to be given daily. It was noted that the 1 and ? tabs had been stricken through and the word "error" was written followed by two initials. In addition, an arrow from the name of the medication to a space below showed "pt takes 1 tab = 20mg daily."

17. During an interview on 08/22/12 at 9:35 AM Staff N, Director of Pharmacy, stated that all orders should be clarified by the nurse with the physician. He stated that the order for Tadalafil as written was dispensed as 1 and ? tablets of 20mg which would mean the prescribed dose was 30 mg.

18. Record review of the physician order sheet dated 08/21/12 at 7:30 PM showed a telephone order received from the physician for the patient's home medication, Tadalafil. The telephone order was to give 20 mg 1 tab po (by mouth) daily. The telephone order was read back to the physician for clarification and signed by Staff H, RN.

19. Review of a fax dated 08/21/12 (and provided to the surveyors on 08/22/12), which was sent to the ordering physician showed the physician stated that he had not been called concerning the dosage of the Tadalafil.

20. During an interview on 08/22/12 at 11:58 AM Staff H stated that she had called the pharmacy to clarify the dosage on the patient's home medication. Staff H stated the patient clarified the order and she gave what the patient said he took at home. Staff H stated that she did not call the physician to clarify the order but did write a telephone order with a dosage change. Staff H stated that she did not call the physician because he was not on call. She stated she did not call the physician who was on call because that physician didn't know the patient.

21. During an interview on 08/22/12 at 2:10 PM Staff D, Director of Med/Surg, stated that it was not acceptable for one of her staff to write a telephone order when the physician had in fact not been called. She stated it was not in the nurse's scope of practice to do so.








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