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Based on review of the medical record and staff interviews, the nursing staff failed to accurately document, monitor, and communicate with other disciplines pressure ulcer findings of patient #1 who was admitted from a long-term care facility.

Patient #1 is a 56 year old female who was transferred from a long-term care facility with complaint of shortness of breath and fever of 104 degrees. The patient had a past history of significant brain injury after a motor vehicle accident and following craniotomy times 2, history of sepsis from Enterococcal, Acinetobacter and MRSA, history of cardiomyopathy with ejection fraction of 30%, hypertension, chronic respiratory insufficiency with placement of tracheostomy, hepatitis C, IV drug abuse, endocarditis, history of DVT left upper extremity, diabetes mellitus, schizophrenia, seizures and dysphagia with placement of a gastrostomy tube. During the nursing assessment and care in the ED the patient was found to have several pressure ulcers. Although the ED physician did mention in his initial assessment that the patient had a 3 cm stage 2 ulcer left upper sacrum, this information was not found in the patient's history and physical. There is a description in the documentation regarding the number of ulcers. The ED nurse documented on admission the presence of a stage 2 and stage 3 decubiti that were open and bleeding with blisters, whereas the unit nurse documented "sacral area noted with 2 x 2 cm stage 2, blister near area. Cleansed area, Allegn dressing applied. No active drainage.

At this point the two ulcers appeared to be consolidated into one wound. An order was obtained for daily dressing changes. Per the Med/Surg/Telemetry Flowsheet there is an assessment block for skin. Within the block is space for free text comments, boxes that can be checked for WNL (within normal limits), see SIR (skin impairment record) and a line to document the Braden score. This score helps to rate and identify the patient risk for skin breakdown. The scale of 9 or less is considered very high risk. For patient #1 her Braden score was 6 (very high risk) throughout her 6 day hospital stay. For several days, the skin assessments were left blank and there were no physical description of the wounds beyond the stage and location. Per the medical record, the patient's dressings were changed daily, she was turned and repositioned hourly and was placed on a specialty bed.

The lack of accurate documentation and descriptive notes regarding the wounds make it difficult to determine how many wounds the patient had at discharge and the condition of the wounds. Patient #1 did have a complicated medical history with multiple co-morbidities that would place the patient at risk for decubitus ulcer. The care and coordination of treatment was lacking between the medical staff and nursing. The care and treatment for pressure ulcers requires a collaborative team approach which includes monitoring and documentation of medical concerns, nutrition and nursing care.

Based on review of the medical record of patient #1, it was determined the hospital failed to include documentation regarding the care and treatment of the sacral pressure ulcers in the discharge/transfer summary, to the community provider for continuity of care.

Patient #1 is a 56 year old female who was transferred from a long-term care facility with complaint of shortness of breath and fever of 104 degrees. The patient had a past history of significant brain injury after a motor vehicle accident and following craniotomy times 2, history of sepsis from Enterococcal, Acinetobacter and MRSA, history of cardiomyopathy with ejection fraction of 30%, hypertension, chronic respiratory insufficiency with placement of tracheostomy, hepatitis C, IV drug abuse, endocarditis, history of DVT left upper extremity, diabetes mellitus, schizophrenia, seizures and dysphagia with placement of a gastrostomy tube.

Although the nursing staff documented the presence of pressure ulcers on admission, there is a lack of documentation including care and treatment in the discharge/transfer summary. The only mention in the discharge summary is one line statement as follows: "She did have a high lactic acid of 2.4, and local dressing to the sacral wound."