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Based on record and personnel file review, policy review and staff interview it was determined the Registered Nurse failed to supervise and evaluate nursing care to ensure the nursing staff had the necessary knowledge and skills to meet the needs of for 1 (#2) of 14 sampled patients related to pressure ulcers.

Findings included:

Patient #2 was admitted on 3/17/16 at 7:56 p.m. for continued care following surgical repair of a hip fracture.

The History and Physical dated 3/18/16 at 10:47 a.m. and signed by the attending physician documented Patient #2's Clinical Impression was encephalopathy, dementia recent hip fracture corrected with surgery, chronic obstructive pulmonary disease, atrial fibrillation, dysphagia (inability to swallow) and Cerebrovascular accident (stroke).

The Admission Nursing Assessment dated 3/18/16 at 2:31 a.m. and signed by the Agency Registered Nurse (Agency RN) included the Nutrition component of the Braden Score (an assessment of the patient's degree of risk for skin breakdown) was "3-probably adequate". The overall score was 13 indicating Patient #2 was at moderate risk of skin breakdown.

On 3/18/16 the initial Weekly Wound Care notes signed by the Wound Care RN indicated Patient #2 had four pressure wounds at the time of admission. The Weekly Wound Care notes dated 6/14/16, one day prior to Patient #2's discharge, signed by the Wound Care RN indicated the patient had a total of 19 wounds documented to be pressure ulcers. Three of the 19 wounds were documented by the Wound Care RN as community acquired. 16 of the 19 pressure wounds were documented by the Wound Care RN as hospital acquired.

The review of the facility policy "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds", #H-WC 01-001 dated 6/2016 revealed the Braden Score required the nursing assessment of six components of patient risk: sensory perception, moisture, activity, mobility, nutrition, and shear for a total possible 23 points. Page 3 of the policy referred to the Kindred Skin Safe Program, an education program for pressure ulcer prevention and treatment. The Kindred Skin Safe Program (no date, no page numbers provided) included the Braden Risk Level as 15-18=Mild Risk, 13-14=Moderate Risk, 10-12=High Risk, 9 and above=Very High Risk. The document included the statement, "Advance one risk level for patients with ...advanced age > 60...Poor intake/decreased protein...cardiac diagnoses/diabetes".

Patient #2 was over 60 years of age, had atrial fibrillation, was unable to swallow, the nutritional status was "probably adequate" and the overall Braden Score of 13 indicated a moderate risk of skin breakdown. The "Advance One Level" in compliance with the facility Skin Safe Program that would have resulted in Patient #2 being at High Risk for skin breakdown.

The review of the personnel files for 6 nurses and one Certified Nursing Assistant (CNA) revealed 5 of the seven sampled staff members involved in the care of Patient #2 had no evidence of having completed the Kindred Skin Safe Program.

An interview was conducted with the Clinical Educator on 6/30/16 regarding the relationship of the Braden Score assessment to nursing interventions for the prevention of the development or worsening of pressure wounds. The Clinical Educator demonstrated the manner in which the entry of various Braden Scores into a patient's medical record resulted in computer generated lists of nursing interventions from which the nurse could select any or all interventions felt were appropriate for a particular patient. The list of interventions for patients at Moderate Risk did not include providing a low air loss mattress. The list of interventions for patients at High Risk did include providing a low air loss mattress.

An interview was conducted with two Certified Wound Care Consultants on 6/28/16. The consultants indicated they had arrived at the facility on May 10, 2016. They indicated their primary focus was educating the nursing staff regarding pressure ulcer prevention and treatment. The consultants confirmed the Braden Score assessment was the basis for all nursing interventions related to pressure wounds. When asked to provide information regarding an evaluation of the accuracy of the current nursing staff's Braden Score assessments, they indicated they had not conducted any assessments and their plan did not include assessing the accuracy of the Braden Scores.

An interview was conducted with the Certified Wound Care Consultants on 6/30/16. They indicated they had begun collecting data on June 1, 2016. To date the data reflected 18 hospital acquired pressure wounds for the month of June. They indicated the 18 hospital acquired pressure wounds were identified by the current RN Wound Care Nurses. They presented data showing the assessments and wound identifications performed by the staff RNs during the admission assessments and the variations of the wound identifications on the same patients following the subsequent evaluation by the RN Wound Care Nurses. They indicated none of the current Wound Care nurses were certified. They indicated they had not verified the accuracy of the Wound Care Nurses wound assessments that had resulted in the identification of 18 hospital acquired pressure ulcers in the month of June. Their plan did not include a formal assessment of the current wound care nurses' knowledge and skills.

Based on medical record review, policy review and staff interview it was determined the facility failed to ensure nursing followed policies and procedures and physician orders to develop, maintain and keep current the care plan for 3 (#2, #11, #12) of fourteen sampled patients.

Findings included

1. The physician orders for Patient #2 dated 3/18/16 and signed by the attending physician included an order to turn and reposition the patient every two hours. The review of the medical record revealed no evidence Patient #2 was turned and repositioned every two hours between 6/1/16 and 6/15/16, the date of discharge. The Weekly Wound Care notes revealed Patient #2 developed a total of 16 new pressure ulcers over the course of the hospitalization.

2. Review of the facility policy "Food and Fluid Intake" stated patient's food and fluid at meals and snacks is monitored to determine adequacy of nutrient intake. The responsible disciplines are licensed nurses and certified nursing assistants". The procedure stated the intake of meal or snack will be determined once the patient has finished consuming the food and/or beverage, the intake will be documented, and notification of the physician and the registered dietitian of intake that has declined for the past 3 consecutive days will be done.

Review of the medical record for patient #11 revealed the patient was admitted to the facility on 6/22/2016 for respiratory insufficiency. On 6/23/2016 the dietician completed a dietary consult.

Review of the dietary consultation revealed the patient was noted to have a poor appetite (50% or less) and required set-up and assistance with feeding. Recommendations were made by the dietician for a change in diet to include consistent carbohydrate restriction as the solumedrol was expected to elevate blood glucose levels. It included monitoring of the patient's caloric intake with an overall estimated need of 1710-1995 calories/day, to assist the patient with feeding, to encourage a slow pace with eating and drinking and to monitor the tolerance to the physician prescribed mechanically soft diet.

Review of physician orders dated 6/23/2016 stated to sit the patient upright 90 degrees, to assist with feeding and slow pace with eating and drinking. Review of the patient's plan of care revealed the patient required increased nutrient needs with a desired outcome of PO (by mouth) intake of >75% and to improve the patient's bowel pattern to avoid constipation and diarrhea.

Review of the patient's oral caloric intake revealed on 6/23/2016 for lunch, documentation revealed the patient ate 3/4 of a sandwich, 1/2 bread and 1/2 fruit. On 6/24/2016 review of the PO caloric intake revealed for breakfast, lunch and dinner the patient ate "all". On 6/25/2016 there was no documentation the patient had any caloric oral intake. On 6/26/2016 the patient received a snack at 9:00 p.m. and documentation revealed the patient ate "all". Review of the medical record revealed on 6/27/2016 and 6/28/2016 there was no documented oral caloric intake.

Review of the documentation revealed no evidence the patient was assisted with feeding, sat upright 90 degrees or encouraged to eat and drink at a slow pace. Review of the patient's oral caloric intake revealed inconsistent measurement and lack of measurement for meal consumption.

Review of the nursing documentation for the patient's bowel pattern/movement revealed the patient had no recorded bowel movement on 6/23, 6/24, 6/25 or 6/26/2016. During review of the medical record with the Interim Chief Clinical Officer on 6/29/2016 at approximately 2:40 pm the above information was confirmed.

3. Review of the medical record for patient #12 revealed the patient was admitted on 6/27/2016. The physician stated the patient presented with diagnosis that included failure to thrive and moderate to severe protein calorie malnutrition.

Review of the nursing admission assessment dated 6/27/2016 at 8:33 p.m. stated the patient was on a regular diet, was able to feed self and had a poor appetite. Review of the physician orders dated 6/27/2016 at 10:00 p.m. stated regular diet with boost plus twice daily.

On 6/28/2016 the dietician completed a dietary consult. Review of the dietary consultation revealed the patient was noted to have a poor appetite (50% or less). required set-up and was able to feed self. Recommendations were made by the dietician for an overall estimated need of 1890-2205 calories/day and to monitor the patient's tolerance to the diet.

Review of the patient's oral caloric intake on 6/28/2016 for lunch revealed "all" and a snack at 8:48 p.m. "all". On 6/29/2016 at 8:25 a.m. the oral intake was not recorded for breakfast.

During review of the medical record with the Interim Chief Clinical Officer on 6/30/2016 at approximately 11:30 a.m. the above information was confirmed.

4. Review of the facility policy "Assessment/Reassessment-Interdisciplinary Patient" stated patient reassessment is based on but not limited to the following: to evaluate patient response to care, treatment and services; and to respond to a significant change in status and/or diagnosis or condition. Physician orders for routine vital signs will be interpreted by nursing personnel as follows: telemetry patients=every 4 hours, ICU (Intensive Care Unit)=every 1 hour. Routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, pain assessment.

Review of the medical record for patient #11 revealed the patient was admitted to the facility on 6/22/2016. The physician's documented plan was to admit to the medical floor on a cardiac monitored bed (telemetry).

Review of the record revealed a nurse reassessed the patient once every 12 hours, not every four hours as per policy. Review of nursing documentation revealed on 6/27/2016 at 6:00 p.m. the nurse was informed by the patient's family member that there was bright red blood spots on the sheet. The RN documented the patient was turned and a large amount of frank red blood and large blood clots were noted. The RN documented three golf ball sized stool was manually taken out of the patient's rectum and noted the patient was actively bleeding from the rectum. Review of the record revealed no evidence of a physician order to manually disimpact stool from the patient's rectum.

Review of the documentation by the CNA (Certified Nursing Assistant) on 6/28/2016 at 2:48 a.m. revealed the patient had rectal bleeding and the RN was notified. Review of the record revealed no documentation the RN reassessed the patient to determine if there was a change in the patient's condition that needed intervention or elevation of the concern to the physician.

During review of the medical record with the Interim Chief Clinical Officer on 6/29/2016 at approximately 1:40 p.m. the above information was confirmed.