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Based on interview and record review the hospital failed to ensure 1 of 4 patients reviewed [Patient #1's] Braden score was not accurately assessed related to pressure ulcers to the coccyx and buttock identified on the admission nursing assessment. The RN further failed to notify the phsyican and wound care nurse. Patient #1 was discharged on 02/16/10 with 6 pressure areas. #1; right medial foot, #2; right heel, #3; right achilles distal, #4 right achilles proximal, #5; stage II pressure ulcer to the right ankle and #6; right buttock blister.

Findings included:

1) Patient #1's history and physical dated 02/10/10 reflected, "the patient has severe dehydration, hypernatremia, hypokalemia, urinary tract infection, acute renal failure, anemia, dementia, chronic obstructive pulmonary disease, questionable history of cerebrovascular accident, gastroesophageal reflux disease and glaucoma."

The 02/10/10 nursing admission assessment timed at 1800 reflected a "Braden score of 14 [moderate risk]...stage 2 sores present on admission." It should be noted the patient had contractures and was totally dependent on staff to meet her needs.

It should be noted it was not until 02/15/10 at 1525 wound orders were obtained by the wound care nurse.

On 04/7/10 at 11:40 AM RN #8 was interviewed. RN #8 was asked by the surveyor to review Patient #1's medical record. RN #8 stated she assessed Patient #1 when she was admitted on 02/10/10 to the floor. RN# 8 stated she documented a braden score of 14. She stated the patient had pressure sores to the buttock and coccyx. RN #8 stated she was scoring the braden at a 14 for the potential for skin breakdown but stated she should of scored Patient #1 at high risk due to actual skin breakdown. RN #8 stated she did not notify the physician or the wound nurse regarding Patient #1's skin breakdown.

The Hospital Policy entitled, "Braden Scale" dated 03/94 reflected, "the Braden scale is used to assess a patient's risk for pressure ulcers...score of 12 or less indicates a patient is at high risk...this score is an indicator of the patient's risk of developing pressure ulcers..."

The Hospital Policy entitled, "Skin and Wound Care" dated 06/95 reflected, "an orders will be written to consult the Wound care Specialist...members of the wound care team will receive notice through the computer or by phone when an order is written to consult wound care specialist."

Based on interview and record review, it was determined the hospital failed to send the necessary medical information needed to ensure treatment of multiple pressure ulcers was provided when 1 of 4 patients [Patient #1] was discharged to a nursing home.

Findings Included:

1) Patient #1's history and physical dated 02/10/10 reflected, "the patient has severe dehydration, hypernatremia, hypokalemia, urinary tract infection, acute renal failure, anemia, dementia, chronic obstructive pulmonary disease, questionable history of cerebrovascular accident, gastroesophageal reflux disease and glaucoma."

The wound care orders dated 02/15/10 timed at 1525 reflected "alleyvn foam to right heel, bilateral waffle boots, leave right buttock blister intact and open to air and notify wound care if area worsens or opens."

The physician discharge orders dated 02/15/10 reflected, "discharge to nursing home..." No orders for wound treatment was found.

The hospital nursing home transfer record and discharge medication administration record dated 02/15/10 reflected, "medications, treatments, dressings, catheters, special teaching... see MAR [medication administration record]..." It should be noted the medication administration record had no documentation regarding treatment/instructions for wound care.

The computerized discharge plan dated 02/16/10 had not documentation which addressed Patient #1's pressure ulcers.

On 04/2/10 at approximately 1:30 PM RN #1 was asked to review the discharge paperwork in Patient #1's medical record. RN #1 stated there was no documentation/instruction and/or orders for treatment of Patient #1's multiple pressure ulcers when discharged on 02/16/10.

The Hospital Policy entitled, "Discharge of Patients" dated 02/90 reflected, "patients will be...provided with discharge instructions, education, and necessary information and/or resources to resume care upon dismissal and appropriate community services and/or agencies, as appropriate to ensure continuity of care..."