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Based on interview, policy and procedure review, and documentation in 1 of 1 record reviewed of a patient with decubitus ulcers (patient #7), it was determined the hospital failed to ensure that the registered nurse evaluated all of the patient's nursing care needs on admission and throughout the hospitalization. There was a lack of initial and on-going assessment related to 6 of 6 alterations of the patient's skin conditions.

1. The following policies were reviewed:
"Skin Care," identified as "Effective: July 2009." The policy and procedure required "Staff will record pertinent skin data on admit, daily and with any changes...Skin impairment is any redness or break in the skin and underlying tissues." The policy and procedure further reflected "Wound assessment and documentation of skin impairment is the basis for planning treatment, evaluating the effects of treatment, creating a skin/wound history and communicating with care givers. Document skin impairment on the patient chart within 24 hours of patient admission; listed below are factors to be assessed at the wound site and documented when appropriate. A. Drainage-1. Amount; 2. Odor after cleaning; and 3. Color. B. Wound Bed-1. Percent of necrosis, (25, 50, 75, 100), and color, (Black, Yellow, Tan); 2. Epithelization absence/presence; and C. Peri-wound-1. Tunneling, (use clock method to indicate location and depth); 2. Undermining, (use clock method to indicate location and depth); 3. Induration; D. Location of wound; E. Size in centimeters; length; width, depth; and F. Wound edges; 3. Granulation absence/presence. 4. Erythema; 5. Desiccation; 6. Maceration; Crepitus; and Fluctuance."

Wound Care/Skin Integrity-Photo Documentation/Evidence Collection," identified as "Effective: April 2009." The policy purpose/policy statement reflected "*To present care guidelines for pressure ulcer prevention; *To document, on admission and at regular intervals, thereafter, (to document progression), the presence of a wound and the surrounding skin...to facilitate communication among members of the interdisciplinary team." The policy and procedure required "Pressure Ulcer Prevention A. Perform a full skin assessment on each adult patient..: 2. If a patient scores at risk on Braden, complete a daily full skin assessment. B. Prevention Interventions for patients at risk include:..7. Creating a nursing order for interventions and placing the issue on the care plan." The policy and procedure further directed "When to Take Photographs...B. When a patient presents with pre-existing wounds, on admission with admission paperwork; C. Upon identification of hospital acquired pressure ulcers or other hospital acquired skin injury-the physician and RN shall stage each pressure ulcer on admission and/or upon new development; D. Pressure ulcers, skin alterations from suspected abuse, and other wounds including, but not limited to, diabetic foot ulcers, arterial ulcers, venous stasis ulcers, open surgical wounds (photograph and document all)...G. Within 48 hours prior to discharge from the hospital. H. Document wounds/skin injuries on the Skin Assessment Documentation record and Wound Photographic Documentation record."

2. Review of the record for patient #7 revealed the patient was admitted on 04/29/11 at 0555 for surgical revision of his/her right knee replacement. The record reflected diagnoses which included diabetes mellitus and a sacral decubitus ulcer. The patient was transferred to the orthopedic unit on 04/29/11 at 1110 and discharged to a skilled nursing facility on 05/03/11. The "Salem Health SKIN INTEGRITY RECORD" dated 04/29/11 included a "man" figure diagram and reflected the following skin conditions and corresponding documentation: The bilateral buttocks areas were identified and reflected "Reddened Area [with] small [approximately] 1cm x 1cm open area;" the right ankle was identified and reflected "Red spot [approximately] 2cm x 2cm;" the front of both lower legs were identified and reflected "Brownish discoloration to lower legs Bilat;" the right knee was identified, however the documentation reflected "6. Surgical incision from L knee Revision ..." The directions on the form reflected "Use Number Code from bottom list with brief description (example: #7 J.P.) Date, Time & Initial Each Site Entry" and included "1. Rash 2. Hematoma 3. Incontinence related 4. Eccymosis 5. Pressure Ulcers..." There was no documentation that clearly described the type of skin conditions and the date and time of each skin condition entry.

Documentation and photographs on the "WOUND ASSESSMENT RECORD" forms on 04/29/11 reflected photographs of the patient's sacrum/ buttocks, the left lower leg, and right lower leg. There was no documentation that described the type of skin conditions, size, color, drainage and surrounding skin, and there was no photograph of the skin conditions within 48 hours prior to discharge in accordance with the policies and procedures.

Documentation on the electronic "RISK ASSESSMENT" flowsheets for 04/29/11 through 05/03/11 for Braden Scales (A scale for predicting pressure sore risk) revealed a score of 20 on 04/29/11 at 1211, and scores of 16 to 18 for the remaining dates. The risk assessment flow sheet reflected only "Incision" for "Wound Type." There was no documentation that clearly identified the patient's individual skin conditions, or the site of the patient's surgical incision. The electronic care plan revealed that a Braden Score of 15-18 indicated the patient was "At Risk" for pressure sores and therefore required a daily full skin assessment. There was no documentation that daily full skin assessments had been completed in order to evaluate wound progress in accordance with the policies and procedures.

Documentation on the electronic physician orders generated by the certified wound ostomy nurse on 05/02/11 at 1409 reflected "Topical Wound Management..." and "Position off the area as much as possible and moisturize the skin. Avoid reclining position." There was no documentation that identified the specific wound site or alteration in the skin condition.

3. During a phone interview on 07/27/11 these findings were reviewed with the RN Manager of Accreditation Services and an opportunity was offered to provide additional information. During a follow up phone interview on 07/28/11 at 1520, the RN Manager of Accreditation Services stated that the implementation of the assessment portion of the electronic medical record replaced the prior "paper record" tools for documenting wound assessments. He/she further added that these changes have created challenges in the documentation of wound assessments. No additional documentation to reflect that nursing care was supervised and evaluated for the patients' skin conditions was provided.

Based on interview, policy and procedure review, and documentation in 1 of 1 record reviewed of a patient with decubitus ulcers (patient #7), it was determined that the hospital failed to ensure that an individualized care plan for 6 of 6 alterations in the patient's skin condition was developed and kept current by the nursing staff, and based on the assessment of the patient and identified patient needs.

Findings include:

1. The following policies were reviewed:
"Coordination of Care from Admission through Discharge," identified as "Effective: March 2010" required "E. The RN develops and documents, within eight hours following admission, an individualized plan of care for the patient, based on the patient assessment and initial care goals...1. The nursing care plan will address appropriate physiological, psychosocial and discharge planning elements...4. All disciplines will document their plan of care in the patient's medical record...6. The plan of care is revised and updated as patient status changes."

"Process for Planning & Providing Care," identified as "Effective: August 2009." The policy and procedure required "A. The plan for provision of patient care is based on the assessment of the patient, identified patient needs and goals, and interventions needed to meet those goals-all disciplines involved in the patient's care contribute to the plan of care...C. Plans of Care are individualized for each patient; goals shall be identified for each problem identified."

Wound Care/Skin Integrity-Photo Documentation/Evidence Collection," identified as "Effective: April 2009." The policy and procedure required "B. Prevention Interventions for patients at risk include:..7. Creating a nursing order for interventions and placing the issue on the care plan."

2. Review of the record for patient #7 revealed the patient was admitted on 04/29/11 at 0555 for surgical revision of his/her right knee replacement. Review of the record revealed the patient had diagnoses which included diabetes mellitus and a sacral decubitus ulcer. The patient was transferred to the orthopedic unit on 04/29/11 at 1110 and discharged to a skilled nursing facility on 05/03/11. The "Salem Health SKIN INTEGRITY RECORD" dated 04/29/11 reflected the following skin conditions and corresponding documentation: The bilateral buttocks areas were identified and reflected "Reddened Area [with] small [approximately] 1cm x 1cm open area;" the right ankle was identified and reflected "Red spot [approximately] 2cm x 2cm;" the front of both lower legs were identified and reflected "Brownish discoloration to lower legs Bilat;" the right knee was identified, however the documentation reflected "6. Surgical incision from L knee Revision ..." There was no documentation that the care plan had been developed, individualized and updated for those skin conditions in accordance with the policies and procedures.

Documentation on the electronic record reflected the following care plan problems: "Integumentary"dated 04/29/11 at 1235 and "Braden Score: 15-18 (At Risk)" dated 04/30/11 at 1516. There was no documentation on the care plan that clearly identified the patient's current alterations in skin conditions and sites. There was no documentation that the care plan had been developed and included individualized goals and interventions for the treatment of those conditions.

Documentation on the electronic physician orders dated 04/30/11 at 1501 reflected "NURSING REFERRAL TO WOUND, OSTOMY CARE RN..." and "Reason for Referral: FULL THICKNESS WOUNDS." There was no documentation that identified the type of wound condition and wound site. There was no documentation that the care plan had been developed and included individualized goals and interventions for the treatment of those conditions.

Documentation on the nursing progress notes dated 05/02/11 at 1757 reflected "Patient has
decub [decubitus] on both buttocks covered with ABD," and 05/03/11 at 0337, "ABD on decub ulcers fell off. Scant amount of serosanguinous drainage noted to old dressing. Wounds are open with small amount of serosanguinous drainage. Wound on left buttock is larger than wound on right. This RN placed Allevyn to both buttock." There was no documentation that the care plan had been developed and included individualized goals and interventions for the treatment of those conditions.

3. During a phone interview on 07/27/11 these findings were reviewed with the RN Manager of Accreditation Services and an opportunity was offered to provide additional information. During a follow up phone interview on 07/28/11 at 1520, the RN Manager of Accreditation Services stated that the implementation of the assessment portion of the electronic medical record replaced the prior "paper record." He/she further added that these changes have created challenges in the documentation of wound care and assessments. No additional documentation to reflect the development of a current and individualized wound care plan and assessment of the patients' skin conditions was provided.