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Based on observations, interviews, and review of facility policy, procedure, and clinical records, the Registered Nurse failed to evaluate and supervise care and services for the prevention and treatment of pressure ulcers for three (#1, #2, #3) of three records reviewed. This practice may cause a prolong patient stay and does not ensure patient goals are obtained.

Findings include:

1. Patient #1's transfer facility's information noted no mention of pressure ulcers. The History and Physical revealed no concerns with pressure ulcers. Review of the nursing admission documentation dated 11/27/09 showed no mention of pressure ulcers. Wound Care nurse documentation on 12/17/09 showed a pressure ulcer to the coccyx that was unstageable. Review of nursing documentation from admission to 12/17/09 did not show evidence of pressure ulcers. The next Wound Care nurse documentation on 12/30/09, thirteen days later, showed a pressure ulcer to the coccyx; stage III. Wound Care nurse documentation showed assessments were performed on 01/06/10, 01/13/10, and on 01/20/10 as a stage IV. Wound care nurse documentation on 02/03/10, fourteen days later, showed a pressure ulcer to coccyx, stage IV. Wound Care nurse documentation on 02/10/10 showed a new pressure ulcer to the right hip, stage I. The note stated the coccyx wound was a Stage IV. Wound Care nurse documentation on 02/25/10, twenty two days later, showed a pressure ulcer to left hip that was unstageable and to the right hip and Coccyx.

2. Patient #2's admission wound care nurse documentation dated 12/9/09 showed the presence of a sacral wound. The documentation noted eschar was present. The next wound care documentation was dated 1/6/10, almost thirty days later. Wound care nurse documentation dated 1/14/10 noted a wound on the left ear. There was no documentation of the sacral being assessed. The wound care nurse next documented on 1/20/10 that the sacral wound remained present and no mention of the ear. The wound care nurse next evaluated the sacrum wound on 1/27/10. Registered Nurse documentation dated 2/13/10 noted a pressure ulcer on the sacrum, left hip, left ear, and right ear, which was scabbed. Wound Care nurse documentation dated 2/17/10 indicated the left hip wound was house acquired, with the depth not being able to be determined, 80% necrotic and classified as a Stage II. The documentation noted the sacral wound was assessed, approximately twenty days after the last assessment.
A Review of the facility's policy number H-WC 02-002 " Wound Assessment and Classification" dated 12/08 indicated a stage II is described as a partial loss of the dermis presenting as a shallow open ulcer with a red pink wound bed without slough.

3. Patient #3's wound care nurse documentation dated 2/2/10 revealed the presence of a left heel pressure ulcer. Interview with the Registered Nurse caring for the patient on 2/26/10 at approximately 9:45 a.m. revealed the presence of a left heel wound with questionable eschar. The interview revealed the wound was first noted on 1/21/10. The clinical record review noted no further notes from the wound care nurse.

The House Supervisor confirmed the findings on the above patients on 2/26/10 at approximately 2:15 p.m.

Interview with the Wound Care nurse on 2/26/10 at approximately 3:40 p.m. revealed wound care assessments are done weekly for four weeks then monthly or as needed.

A review of the facility's policy # H-WC 02-002 "Wound Assessment and Classification" dated 12/08 indicated weekly assessments are to be done by the Wound Care Coordinator/designee.

The review of wound care nurse documentation and the interview did not reveal evidence of care being provided in accordance with the facility policy and procedure.


4. Patient #1's nursing documentation revealed on random dates from 12/01/09 to 02/20/10, 14 out of 21 days, showed the patient had not been turned every 2 hours as per facility policy and procedure. On 12/02/09 the patient was on the right side from 8:16 a.m. to 12:25 p.m. On 12/15/09 the patient was supine at 4:03 a.m. and also on the left side at 4:03 a.m., than again at 6:57 a.m. on the right side and supine at the same time. The patient was in the supine position from 9:58 a.m. to 14:32 p.m. On 12/16/09 the patient was on the left side from 5:56 a.m. to 10:00 a.m., on left side from 1:34 p.m. to 6:15 p.m., and on the right side from 6:15 p.m. to 11:05 p.m. On 01/05/10 the patient was on left side from 2:00 a.m. to 6:13 a.m. On 01/06/10 the patient was on left side from 6:40 a.m. to 10:00 a.m. On 01/07/10 the patient was in the supine position from 4:25 p.m. to 9:32 p.m. On 01/16/10 the patient was on the left side from 6:00 p.m. to 9:50 p.m. On 01/27/10 the patient was on the right side from 2:00 a.m. to 5:54 a.m. On 01/28/10 the patient was on the right side from 6:59 p.m. to 11:31 p.m. On 02/10/10 the patient was in the supine position from 6:00 a.m. to 10:44 a.m. On 02/11/10 the patient was on the left side from 2:00 a.m. to 7:32 a.m. 02/19/10 the patient was on left side from 10:10 a.m. to 2:50 p.m. On 02/20/10 the patient was on the right side from 4:00 a.m. to 8:10 a.m.

Facility policy and procedure "Pressure Wound Treatment" #H-WC- 03-001 dated 2/07 revealed patients are to be turned every 2 hours.

Interview with the Registered Nurse caring for the patient on 2/25/10 at approximately 10:55 a.m. revealed the patient had pressure ulcers on sacral area, right hip, and left ear. The interview noted the pulse lavage was on hold and the patient was receiving Nystatin to the buttocks.

Interview with the Wound Care nurse at 11:10 a.m. revealed the nurse was not sure if the pulse lavage was still on hold. Review of physician orders did not show an order to hold the pulse lavage.

Observation of the patient in the PCU (Progressive Care Unit) on 02/25/09 at approximately 11:45 a.m. revealed two wound care nurses at the patient ' s bedside. Observation of the patient showed a dressings to coccyx, right and left hips, and pressure ulcer to left ear. When questioning the two wound care nurses about the wound care treatments, they reported using Santyl and pulse lavage on the coccyx and left hip wounds. The interview revealed hydrogel was being used on the right hip and the left ear was open to air. Physician order dated 01/13/10 instructed for Pulse lavage to sacral wound Monday thru Friday and on 12/17/09 to cleanse the sacrum with wound cleanser, apply MeSalt to wound bed, cover with border gauze, and change every day. Physician order dated 12/16/10 instructed for Santly every shift. Review of Physical Therapy documentation from 1/13/10 to 2/25/10 revealed pulse lavage was done with Mesalt and border gauze Monday through Friday. The interviews and review of the documentation and physician orders noted conflicting care was being provided to the pressure ulcers. There were no physician orders for care of the right hip, left hip, or left ear wounds.

5. Patient #2's nursing notes for eight random days between 1/10/09 and 2/16/10 revealed the patient was not turned every two hours. On 1/12/10 the patient remained on the left side from 2:00 a.m. to 8:00 a.m. and from 2:53 p.m. to 6:20 p.m. On 2/14/10 the patient remained on the left side from 5:43 p.m. to 10:00 p.m. On 2/15/10 at 10:14 a.m. the patient was on the right side and was not turned until 2:29 p.m. Om 2/16/10 at 6:32 a.m. the patient was turned to the left and was not turned again until 10:48 a.m.

Interview with the Registered Nurse caring for the patient on 2/26/10 at approximately 10:05 a.m. revealed the sacral wound and a right ear wound. The interview did not reveal knowledge of the left hip or ear wound.

Facility policy and procedure "Pressure Wound Treatment" #H-WC- 03-001 dated 2/07 revealed patients are to be turned every 2 hours.

Based on interview and review of clinical records; pressure ulcer logs; and tracking and trending information, the facility failed to monitor the effectiveness and quality of care for pressure ulcer prevention and treatment for three (#1, #2, #3) of three records reviewed. This practice does not promote improved patient care and outcomes.

Findings include:


1. Review of house acquired pressure ulcer logs for 11/09 through 2/10 revealed patient #1, who was observed in the Progressive Care Unit (PCU) was listed for a deep tissue injury pressure ulcer on the right hip dated 2/10/10. Review of the clinical record and observation on 2/25/10 at approximately 11:45 a.m. noted the presence of pressure ulcers on the left ear, right and left hip, and the sacral area. There was no evidence of the wounds being present on admission. There was no entry for the sacral, left hip, or ear wound on the log.

2. Review of house acquired pressure ulcer logs for 11/09 through 2/10 revealed an entry for patient #2. Review of the clinical record noted a community acquired sacral wound. The clinical record noted house acquired pressure ulcers on both ears and the left hip. Review of the log noted an entry 2/10, no date, of a right hip wound.

3. Review of house acquired pressure ulcer logs for 11/09 through 2/10 revealed an entry for patient #3. Review of the clinical record revealed a house acquired pressure ulcer on the left heel. Review of the logs dated 1/21/10 revealed deep tissue injury to the heel that was not stageable. The log did not show if it was the right, left, or both heels.

4. Sixteen of 19 entries in the log did not show which unit the pressure ulcer developed. Two of the 19 entries were completed for all information requested such as number of wounds, risk score, consult for dietary and wound care, and
support surface.

Wound Care nurse interview on 2/26/10 at approximately 3:50 p.m. revealed she completed the log, gives the information to Quality Improvement, and does not do any tracking or trending.

Interview with the Director of Quality Management and review of tracking and trending information revealed monthly statistic are provided by the computer system based on the wound score assigned. There was no other information for tracking or trending or rational for the discrepancies in the logs versus clinical records.