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Based on hospital policy and procedure review, open and closed medical record review, and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to assess and provide interventions for 3 of 7 sampled patients with pressure ulcers (Patient #9, #10 and #3).

The findings include:

Review of the Hospital's Policy titled "Pressure Ulcer Prevention and Management/Skin Tears/MASD (Moisture Associated Skin Damage)/Wounds/Incisions, Risk Assessment", revised date: 02/2016, revealed "...Policy: For Patients on Inpatient Units,... Patients are assessed for risk of skin breakdown upon admission, every shift and as warranted by changes in patient condition: Use the Braden Scale, ..., as appropriate. Patients are assessed for existing skin breakdown upon admission and every shift. ...2. To prevent skin breakdown, implement basic prevention measures for patients and individual interventions based upon Braden Scale Subscores. Refer to Pressure Ulcer Prevention Guidelines (Appendix A) for guidance... Behavioral Health: All patients are assessed for risk of skin breakdown upon admission and as warranted by change in patient condition..."

Review of "Appendix A: Pressure Ulcer Prevention Guidelines" revealed "Individualized Braden Sub-Score Interventions ...Mobility Subscore 3:..Encourage patient to assist with repositioning Reposition q2 (every 2) hour...Float heels at all times Consider PT/OT (Physical Therapy/Occupational Therapy) evaluation if change from prior level of functioning..."

1. Open medical record review on 09/22/16 for Pt #9 (Patient) revealed a 70 year old male admitted on 09/19/2016 at 0305 with a diagnosis of "Aspiration Pneumonia" (lung problem) and "Infected Decubitus" (pressure ulcer). Review of Physician's Orders dated 09/19/2016 at 0514 revealed an order to rinse right sacrum/hip area with Normal Saline and then apply Silvercel (wound dressing) and ABD (abdominal) pad to right hip daily. Review of nursing notes revealed documentation of dressing change on 09/19/2016, on 09/21/2016 and 09/22/2016. Further review of nursing notes revealed no available documentation of a dressing change on 09/20/2016.

Interview on 09/22/2016 at 1400 with AS #2 (Administrative Staff) revealed the nursing staff did not follow the hospital's policy for assessing and providing interventions for pressure ulcers. Interview confirmed the findings.

2. Open medical record review on 09/21/2016 for Pt #10 revealed an 88 year old female admitted on 09/19/2016 at 1445 with a diagnosis of "Sepsis" (bacterial infection). Review of Physician's Orders dated 09/19/2016 at 1602 revealed an order to apply ABD pad with paper tape daily. Further review of Physician's Orders dated 09/19/2016 at 1648 revealed an order to soak with 1/4 strength Dakin's Solution (used to treat skin infection) for 10 minutes daily, rinse sacrum (buttock) area with Normal Saline and then apply SilverCel and cover with ABD pad and tape daily. Review of nursing notes revealed documentation of dressing change on 09/19/2016 and on 09/21/2016. Further review of nursing notes revealed no available documentation of a dressing change on 09/20/2016.

Interview on 09/21/2016 at 1100 with AS #2 (Administrative Staff) revealed the nursing staff did not follow the hospital's policy for assessing and providing interventions for pressure ulcers. Interview confirmed the findings.

3. Closed medical record review on 09/20/2016 for Pt #3 revealed a 76 year old male admitted on 02/21/2016 at 1518 with a diagnosis of "Impaired Insight / Judgement" and discharged on 03/17/2016. Review of Nursing Integumentary (Skin) Assessment dated 02/21/2016 at 1615 revealed documentation of skin warm, smooth and pink and named patient was independent with positioning and ambulation. Further review dated 02/22/2016 at 0102 revealed documentation of "meets skin standard" and a Braden Score (Guideline used to measure need for skin interventions) of "22" (less than or equal to 19 requires interventions). Review of Nursing Assessment dated 02/29/2016 at 2135 revealed Pt #3 required 1-person assist with ambulation. Further review revealed documentation dated 03/02/2016 at 1157 revealed Pt #3 required 2-person assist with ambulation. Review of Nursing Integumentary Assessment dated 03/03/2016 at 0730 revealed documentation of "blister on bony prominence of left heel" with a Braden Score of "19" with Mobility Score of "3". Further review dated 03/04/2016 at 0800 revealed documentation of "blister left heel" with Braden Score of "19". Review of Nursing Integumentary Assessment revealed documentation on 03/06/2016 through 03/11/2016 of blister on left heel. Review of Nursing Integumentary Assessment dated 03/12/2016 at 1400 revealed documentation of "bil (bilateral) heel L (left) darkened, R (right) red and dark area". Review of Nursing Progress Notes dated 03/12/2016 at 1414 revealed documentation of patient's "heels elevated on pillow and heel protectors placed bilaterally". Further review of Nursing Assessment and Notes revealed documentation of heel protectors on 03/13/2016 at 1000, 2147 and 2302, on 03/15/2016 at 0407 and 0853, on 03/16/2016 at 1140 and 1945, on 03/17/2017 at 0800 of heel protectors in place. Review of Nursing Assessment revealed no available documentation of skin prevention interventions from 03/03/2016 at 0730 through 03/12/2016 at 1414. Further review of Nursing Assessment revealed no available documentation of skin prevention interventions on 03/15/2016 from 7p-7a. Review of Nursing Discharge Note dated 03/17/2016 at 1134 revealed documentation of "skin intact except small excoriated area on L (left) buttock". Further review of Nursing Notes revealed no documentation of the provider notified or interventions initiated for excoriated area on Left buttock. Further review of Pt #3's medical record revealed documentation of skin integrity problem added to patient's Plan of Care on 03/12/2016 (9 days after skin integrity problem identified).

Interview on 09/20/2016 at 1525 with NM #1 (Nurse Manager) revealed the staff are expected to document skin interventions based on Braden Score and Subscores. Interview revealed the staff are expected to notify the providers of any changes in skin integrity. Interview revealed the staff should have performed the dressing changes as ordered by the provider. Interview confirmed the findings.

Interview on 09/21/2016 at 1100 with AS #2 (Administrative Staff) revealed the nursing staff did not follow the hospital's policy for assessing and providing interventions for pressure ulcers. Interview confirmed the findings.

NC00119776

Based on hospital policy and procedure review, open and closed medical record review, and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to ensure a plan of care was updated for 4 of 7 sampled patients with skin integrity problems (Patient #8, #10, #3 and #4).

The findings include:

Review of the Hospital's Policy titled "Plan of Care" reviewed 02/2016, revealed "...POLICY...e. The plan of care will be revised based on on-going assessments, patient response or significant changes in the patient's condition..."

Review of the Hospital's Policy titled "Pressure Ulcer Prevention and Management/Skin Tears/MASD (Moisture Associated Skin Damage)/Wounds/Incisions, Risk Assessment", revised date: 02/2016, revealed "...Procedure: ...5. Interventions are incorporated into the patient's plan of care, evaluated and revised as the condition of the patient indicates... Behavioral Health: ...Nursing staff to incorporate preventive and treatment interventions in the treatment plan for patient found to be at risk. ...Documentation: ...Plan of Care - 'Risk/Actual Skin Integrity Impairment' is initiated if patient is identified to be at risk of skin breakdown or has existing skin breakdown."

1. Open medical record review on 09/22/2016 for Pt #8 revealed an 84 year old female admitted on 09/20/2016 at 2204 with "Acute Encephalopathy" and "UTI" (Urinary Tract Infection). Review of Physician's H&P (History & Physical) dated 09/20/2016 at 2029 revealed documentation of a Stage II (Partial thickness loss of skin - shallow open sore) sacral decubitus (buttock sore). Review of Physician's Orders dated 09/20/2016 revealed an order to apply Bacitracin Ointment (medication) and a sterile 4 x 4 dressing twice a day. Review of the Nursing Plan of Care revealed no available documentation of a skin integrity or pressure ulcer problem initiated (2 days after admission).

Interview on 09/22/2016 at 1400 with AS #2 (Administrative Staff) revealed a nursing plan of care should be initiated on admission and with any changes in patient's condition or identified problems. Interview confirmed the findings.

2. Open medical record review on 09/21/2016 for Pt #10 revealed an 88 year old female admitted on 09/19/2016 at 1445 with a diagnosis of "Sepsis" (bacterial infection). Review of Physician's Progress Notes dated 09/19/2016 at 1539 revealed documentation of a Stage III (full thickness tissue loss) sacral decubitus ulcer (buttock sore) with tunneling (channels that extend from wound) and foul smell. Review of Nursing Plan of Care revealed documentation of a Pressure Ulcer Problem initiated on 09/21/2016 at 0236 (2 days after pressure ulcer identified on admission). Further review of Plan of Care revealed a Skin Integrity Problem initiated on 09/21/2016 at 1553 (2 days after skin integrity identified on admission).

Interview on 09/22/2016 at 1400 with AS #2 (Administrative Staff) revealed a nursing plan of care should be initiated on admission and with any changes in patient's condition or identified problems. Interview confirmed the findings.

3. Closed medical record review on 09/20/2016 for Pt #3 revealed a 76 year old male admitted on 02/21/2016 at 1518 with a diagnosis of "Impaired Insight / Judgement" and discharged on 03/17/2016. Review of Nursing Integumentary Assessment dated 03/03/2016 at 0730 revealed documentation of "blister on bony prominence of left heel" with a Braden Score of "19" with Mobility Score of "3". Review of Nursing Integumentary Assessment dated 03/12/2016 at 1400 revealed documentation of "bil (bilateral) heel L (left) darkened, R (right) red and dark area". Review of Nursing Progress Notes dated 03/12/2016 at 1414 revealed documentation of patient's "heels elevated on pillow and heel protectors placed bilaterally". Review of Nursing Discharge Note dated 03/17/2016 at 1134 revealed documentation of "skin intact except small excoriated area on L (left) buttock". Further review of Nursing Notes revealed no documentation of the provider notified or interventions initiated for excoriated area on Left buttock. Further review of medical record revealed documentation of skin integrity problem added to Pt #3's Plan of Care on 03/12/2016 (9 days after skin integrity problem identified).

Interview on 09/21/2016 at 1100 with AS #2 (Administrative Staff) revealed a nursing plan of care should be initiated on admission and with any changes in patient's condition or identified problems. Interview confirmed the findings.

4. Closed medical record review on 09/21/2016 for Pt #4 revealed at 67 year old male admitted on 02/29/2016 at 1750 with a diagnosis of "Hypotension" and discharged on 03/07/2016. Review of Nursing Notes dated 02/29/2016 at 2115 revealed documentation of abrasions to both legs with right leg being worse, bruising to left lower quadrant of abdomen and left anterior thigh. Review of record revealed no available documention of skin integrity problem added to Pt #4's Plan of Care from 02/29/2016 (date of admission) through 03/07/2016 (date of discharge).

Interview on 09/22/2016 at 1400 with AS #2 (Administrative Staff) revealed a nursing plan of care should be initiated on admission and with any changes in patient's condition or identified problems. Interview confirmed the findings.

NC00119776