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Based on staff interviews, and the review of medical records and other documents, it was determined that nursing staff failed to implement the facility's policy and procedure to assure the prevention and treatment of pressure ulcers. Specifically, nursing staff failed to develop an individualized care plan that includes timely implementation of preventive measures and a schedule for the turning and repositioning of patients identified at risk for developing pressure ulcers. This finding was noted in 2 of 8 applicable records reviewed (Patients #1 and #2,).

Findings include:

1. Patient #1 is a 59 year-old male with a history of quadriplegia (paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso) and neurogenic bladder (a dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of urination), secondary to spinal cord injury. The patient was admitted to the facility on 5/26/14 and underwent an elective surgery on 5/28/14 that included radical cystoprostatectomy (a surgical procedure in which the urinary bladder and prostate gland are removed, and usually also the removal of blood supply, lymph nodes and sometimes adjacent structures of the removed organ), pelvic lymph node dissection (the process of disassembling and observing something to determine its internal structure and condition) and an ileal conduit urinary diversion (a surgical technique for the diversion of urine after a patient has had their bladder removed; an ileal conduit is made in order to drain the urine into a detached section of ileum, a part of the small intestine; the end of the ileum is then brought out through an opening, a stoma in the abdominal wall; and the urine is collected through a bag that attaches on the outside of the body over the stoma).

The initial nursing assessment identified the patient as a high risk for developing pressure ulcer evidenced by his Braden score of 11 (score of 9 or less very high risk; score of 10-12 high risk; score of 13-14 moderate risk; score of 15-18 mild risk; and score of 19-23 no risk). Nursing documentation was inconsistent regarding the patient's skin condition on admission. The assessment on 5/26/14 indicated the patient had a community acquired pressure ulcer located on the right hip, but there was no further description of the pressure ulcer. Another document on 5/26/14 showed a diagram of a healed incision and hypertrophic scar (a raised scar that is usually red and thick and may be itchy or painful which does not extend beyond the boundary of the original wound) on the patient's left hip. Subsequent nursing assessments on 5/27, 5/28 and 5/29 indicate an intact skin with a healed sacral ulcer (an ulcer on the skin that forms at the location of the sacrum, the large triangular bone at the base of the spine and at the upper back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones).

The patient's care plan developed on 5/26/14 listed preventive skin care interventions that were documented daily in the skin assessment record; however, these interventions were not individualized for the patient. There was no established turning and reposition schedule and there was no indication of timely provision of a specialty bed for pressure reduction as prescribed by the facility's policy and procedure.

The facility's policy and procedure titled "Comprehensive Skin Care and Pressure Ulcer Prevention", last revised January 2014, notes that "Pressure Ulcer Prevention Interventions" will include the following pressure reduction measures: "Optimize mobilization; establish a turning and repositioning schedule every two hours; elevate heels off of the bed surface and consider a specialty bed".

At interview with Staff #1 on 7/28/14 at 12:45 PM, she stated patients at risk for developing pressure ulcers are repositioned every two hours and there is no established schedule for each patient.

Staff #2 on 7/29/14 at 11:15 AM stated that the determination for a specialty bed is made on admission and whenever a patient's clinical or functional status changes. She added that the delivery of a specialty bed takes twenty-four hours after it has been ordered.

An order for a Specialty bed written for Patient #1 on 5/26/14 was not implemented until 5/30/14; four days post admission. On the same day, the patient was noted to have developed a deep tissue injury to his sacrum. At discharge from the facility on 7/14/14, the patient had a stage II sacral ulcer, and unstagable ulcers on his right and left hips.


2. Review of medical record for patient #2 on 7/28/14 noted this 64-year-old patient presented to the Emergency Department on 2/15/14 with complaints of "urinating blood, nausea, and abdominal pain". The patient's medical history included stage IV uterine cancer diagnosed at another hospital.

The changes in the patient's skin condition were not timely identified and treated. The patient's skin was intact on admission, but the initial nursing assessment identifies the patient as a high risk for developing pressure ulcers. On 3/20/14, the patient is noted with stage II pressure ulcer to the sacrum. The measurement of the sacral decubitus on 3/23/14 reveals a 6 cm x 1 cm ulcer with scant exudate. On 3/25/14, a second pressure ulcer to the sacrum was identified as a stage III measuring 2.5 cm x 1.0 cm. The two hospital acquired pressure ulcers on the patient's sacrum were identified when they were stages II and III respectively. This finding was brought to the attention of Staff #3. (cm = centimeter = one hundredth of a meter = 0.3937 inches)



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Based on staff interviews, and the review of medical records and other documents, it was determined that nursing staff failed to implement the facility's policy and procedure to assure the prevention and treatment of pressure ulcers. Specifically, nursing staff failed to develop an individualized care plan that includes timely implementation of preventive measures and a schedule for the turning and repositioning of patients identified at risk for developing pressure ulcers. This finding was noted in 2 of 8 applicable records reviewed (Patients #1 and #2,).

Findings include:

1. Patient #1 is a 59 year-old male with a history of quadriplegia (paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso) and neurogenic bladder (a dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of urination), secondary to spinal cord injury. The patient was admitted to the facility on 5/26/14 and underwent an elective surgery on 5/28/14 that included radical cystoprostatectomy (a surgical procedure in which the urinary bladder and prostate gland are removed, and usually also the removal of blood supply, lymph nodes and sometimes adjacent structures of the removed organ), pelvic lymph node dissection (the process of disassembling and observing something to determine its internal structure and condition) and an ileal conduit urinary diversion (a surgical technique for the diversion of urine after a patient has had their bladder removed; an ileal conduit is made in order to drain the urine into a detached section of ileum, a part of the small intestine; the end of the ileum is then brought out through an opening, a stoma in the abdominal wall; and the urine is collected through a bag that attaches on the outside of the body over the stoma).

The initial nursing assessment identified the patient as a high risk for developing pressure ulcer evidenced by his Braden score of 11 (score of 9 or less very high risk; score of 10-12 high risk; score of 13-14 moderate risk; score of 15-18 mild risk; and score of 19-23 no risk). Nursing documentation was inconsistent regarding the patient's skin condition on admission. The assessment on 5/26/14 indicated the patient had a community acquired pressure ulcer located on the right hip, but there was no further description of the pressure ulcer. Another document on 5/26/14 showed a diagram of a healed incision and hypertrophic scar (a raised scar that is usually red and thick and may be itchy or painful which does not extend beyond the boundary of the original wound) on the patient's left hip. Subsequent nursing assessments on 5/27, 5/28 and 5/29 indicate an intact skin with a healed sacral ulcer (an ulcer on the skin that forms at the location of the sacrum, the large triangular bone at the base of the spine and at the upper back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones).

The patient's care plan developed on 5/26/14 listed preventive skin care interventions that were documented daily in the skin assessment record; however, these interventions were not individualized for the patient. There was no established turning and reposition schedule and there was no indication of timely provision of a specialty bed for pressure reduction as prescribed by the facility's policy and procedure.

The facility's policy and procedure titled "Comprehensive Skin Care and Pressure Ulcer Prevention", last revised January 2014, notes that "Pressure Ulcer Prevention Interventions" will include the following pressure reduction measures: "Optimize mobilization; establish a turning and repositioning schedule every two hours; elevate heels off of the bed surface and consider a specialty bed".

At interview with Staff #1 on 7/28/14 at 12:45 PM, she stated patients at risk for developing pressure ulcers are repositioned every two hours and there is no established schedule for each patient.

Staff #2 on 7/29/14 at 11:15 AM stated that the determination for a specialty bed is made on admission and whenever a patient's clinical or functional status changes. She added that the delivery of a specialty bed takes twenty-four hours after it has been ordered.

An order for a Specialty bed written for Patient #1 on 5/26/14 was not implemented until 5/30/14; four days post admission. On the same day, the patient was noted to have developed a deep tissue injury to his sacrum. At discharge from the facility on 7/14/14, the patient had a stage II sacral ulcer, and unstagable ulcers on his right and left hips.


2. Review of medical record for patient #2 on 7/28/14 noted this 64-year-old patient presented to the Emergency Department on 2/15/14 with complaints of "urinating blood, nausea, and abdominal pain". The patient's medical history included stage IV uterine cancer diagnosed at another hospital.

The changes in the patient's skin condition were not timely identified and treated. The patient's skin was intact on admission, but the initial nursing assessment identifies the patient as a high risk for developing pressure ulcers. On 3/20/14, the patient is noted with stage II pressure ulcer to the sacrum. The measurement of the sacral decubitus on 3/23/14 reveals a 6 cm x 1 cm ulcer with scant exudate. On 3/25/14, a second pressure ulcer to the sacrum was identified as a stage III measuring 2.5 cm x 1.0 cm. The two hospital acquired pressure ulcers on the patient's sacrum were identified when they were stages II and III respectively. This finding was brought to the attention of Staff #3. (cm = centimeter = one hundredth of a meter = 0.3937 inches)



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