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Based on medical record review, staff interviews, and facility policy, the nursing staff failed to develop and update a care plan according to the needs of patients and facility policy.
Review of facility policy #PE.005, issued 9/08, revised 3/18, revealed that the Registered Nurse (RN) assesses the patient and formulates patient care goals using an interdisciplinary treatment plan within eight hours of admission. Ongoing assessments are conducted by a Registered Nurse as warranted by the patient's condition, significant changes, and at least every 24 hours. The nursing staff cooperates with physicians and other clinical disciplines when formulating patient care needs. Nursing staff meets with the treatment team within 72 hours of admission to complete the Interdisciplinary Treatment Plan and review and update it every 7 days from admission.
A review of facility policy, PE.012, "Reassessment", issued 9/08, revised 2/16, revealed that reassessment is conducted by a Registered Nurse (RN) every 24 hours at a minimum. RN findings are documented in the patient ' s chart. The attending physician reassesses at the time of each daily patient visit. The reassessment is documented in the patient ' s chart. As indicated by the patient's condition, length of stay, and level of care, the treatment team reassesses the patient in relation to progress toward treatment plan goal. These reassessments are documented on the Interdisciplinary Treatment Plan Update form.

During a medical record review of Patients #1, 2, 3, 4, 5, and 6 it was revealed that Patients #1 and #3 lacked a care plan that addressed skin integrity concerns when indicated.

Patient #1 ' s initial nursing assessment dated 1/1/20 at 5:49 p.m. by a Registered Nurse (RN FF) revealed that the patient ' s general appearance was disheveled, unkempt, and had an offensive odor. The nurse (RN FF) identified stage I redness with buttocks indicated on the body diagram on the nurse assessment sheet; presence of a pressure wound was checked under the nutritional screening section of the initial nursing assessment form. Initial nursing assessment by RN FF also indicated urinary incontinence. The Braden Scale (a system used to rate and identify risk factors for pressure ulcers) score was 15 (a Braden score of less than 16 indicates an increased risk for developing pressure ulcers.) RN FF indicated on the Braden Scale very limited activity, requiring moderate to maximum assistance moving. Review of the initial and master treatment plans revealed that skin integrity was not added to patient ' s treatment plan initially; and the treatment plan was not updated to include skin integrity problems.

A medical record review of Patient #3 revealed that the patient was admitted to the facility 10/21/2020 at 2:25 p.m. with no pressure wound noted on the physician ' s daily progress notes until 10/31/2020 at 1:28 p.m. On 10/31/2020, a stage II pressure ulcer to the buttocks area and a wound care nurse assessment were documented by Physician LL. On 11/2/2020, a stage I sacral wound was documented in Physician LL ' s progress notes, with a plan to continue barrier cream. On 11/5/20, Physician LL documented a Stage II pressure ulcer on the buttocks. On 11/7/20, Patient #3 was transferred to the Emergency Department (ED) for an evaluation. Patient #1 presented among other conditions with a buttock ulcer and was groggy.
Nurse progress notes for Patient #3 failed to reveal a pressure wound on the initial assessment completed 10/22/19. The nurse indicated that the patient was chairfast, had very limited mobility, had a potential for friction/shear, and was over 65 years old. The initial treatment plan 10/20/19 failed to reveal skin integrity problems. The Master Treatment Plan failed to reveal wound care or skin integrity concerns and the master treatment plan was not updated or repeated every 7 days.
During an interview with the Director of Clinical Services (DCS JJ), 2/11/2020 at 10:44 a.m. in the Conference Room, DCS JJ stated that there is to be a treatment team meeting daily, where any redness or skin integrity problems would be identified and put on the patient ' s care plan.
During an interview with RN FF, on 2/11/20 at 2:51 p.m. in the Conference Room, RN FF stated that a wound would be included in the patient ' s treatment plan.
During an interview with RN HH on 2/11/20 at 10:27 a.m. in the Conference Room, RN HH stated that a patient with a wound would have a skin integrity treatment plan.