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Based on record reviews and interviews, the facility failed to ensure that patient safety requirements were met for 1 of 1 patients (#1) reviewed. The facility failed to ensure that patient #1 actually received a specialty air mattress and wound care consult as ordered by his physician. As a result, Patient #1 developed a secondary pressure ulcer on his scrotum and possible worsening of his existing ulcer on the left buttock during his inpatient admission.


This deficient practice also had the potential to cause injury and/or harm to all patients receiving treatment in the facility.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Cross refer: A 0144

Based on record reviews and interviews, the facility failed to ensure that patient safety requirements were met for 1 of 1 patients (#1) reviewed. The facility failed to ensure that patient #1 actually received a specialty air mattress and wound care consult as ordered by his physician. As a result, Patient #1 developed a secondary pressure ulcer on his scrotum and possible worsening of his existing ulcer on the left buttock during his inpatient admission.


This deficient practice also had the potential to cause injury and/or harm to all patients receiving treatment in the facility.


Findings include:


Record review of the clinical record for Patient #1 on 1/25/17 revealed that he was a 25 year old male who was admitted on 5/03/16 with diagnosis of Retrocardiac pneumonia, adrenal leukodystrophy, and protein calorie malnutrition. Further review revealed he was profoundly developmentally disabled and was bed bound with a history of pressure ulcers.


Review of the physician's orders for patient #1 revealed the following orders:


- 5/03/16 @ 8:25 pm : (Swift Orders) Air mattress/ bed or overlay due to pressure ulcers or high risk for developing one.

- 5/07/16 @ 10:00 am: Wound Care evaluation.

- 5/07/16 @10:00 am: Please obtain air mattress (second request).


Further review of the physician's orders revealed no evidence that orders were obtained for wound care for Patient #1's pressure ulcers prior to discharge on 5/09/17.


Record review of the nursing documentation revealed the following:


Form entitled: Pressure ulcer identification form, dated 5/03/16 @ 10:00 pm:


Two areas on the form were checked for pressure ulcer status and were as follows:

-Pressure ulcer present on admission (Yes) Left Buttock. Skin intact with non-blanchable redness and

- Pressure ulcer present on admission (Yes) Left buttock. Full thickness tissue loss subcutaneous fat may be visible but bone, muscle or tendon is not exposed.
Record review of the nursing assessments for Patient #1 reveled the following:


Skin interventions were documented as follows:

5/04/16- 5/06/16:

- Use barrier ointment
- Turn every 2 hours
- Heels off bed
- Heel check
- Redistribution of skin surface
- Condom catheter


5/07/16 @ 10:59 am - 5/08/16 @ 10:21 pm:
- Use barrier ointment
- Turn every 2 hours
- Heels off bed
- Heel check
- Redistribution of skin surface


There was no documentation present for Saturday 5/07/16 @12:22 am- 10:00 am.


-Wound Documentation:


From 5/04/16 @ 2:43 am to 5/06/16 @ 9:46 pm, only one pressure ulcer was documented as follows: (Wound 1) Buttock pressure ulcer, approximated redness, open epidermal, moist wound bed.


On 5/07/16 @ 10:59 am to 5/07/16 @ 10:51 pm, a secondary pressure ulcer is documented as follows:

-(Wound1) Buttock pressure ulcer, redness. Community acquired: yes. Reddened, serosanguinous drainage, dressing changed. Dressing type: dry gauze.

-(Wound 2) Scrotal pressure ulcer. Redness non-blanchable. Cleaned, wound ointment applied.


Record review of the Photographic Wound documentation revealed that on 5/07/16 @ 11:50 am, Licensed Vocational Nurse (LVN)-A obtained photographic documentation of a pressure ulcer to Patient #1's left buttock which was approximately 4 inches in length and 3.5-4 inches in diameter. There is what appears to be a centralized area of black eschar and surrounding skin erythema. In addition, a secondary scrotal ulcer was also photographed which appeared to be open, with a moist, reddened wound bed. Scale is unable to be determined due to a lack of measurement tool in photographic documentation. There was no evidence that nursing staffs photographically documented Patient #1's pressure ulcer on admission.


Further review of the documentation revealed no evidence that the wound care nurse assessed or treated Patient #1 for his pressure ulcers before his discharge on 5/09/16. Also, there was no evidence of central supply requisitions/ documentation to show Patient #1 received a specialty air mattress.


Record review of the facility Policy entitled: Interdisciplinary Admission Assessment and Reassessment, Dated 08/2016 revealed in part the following:


M.) Wound Ostomy Nurse:

2.) Nursing staff notify the facility wound ostomy nurse and physician upon identification of a pressure ulcer, and wound care orders are obtained from the physician using facility order sets. Nursing staff utilize the pressure ulcer prevention standing delegated orders for high risk patients and patients with pressure ulcers.


Record review of the facility policy entitled: Guidelines for Identification, Prevention, and Management of Pressure ulcers, dated 09/2014 revealed in part the following:


C.) Section Entitled: Documentation of Pressure Ulcers:

1.) The nurse on the inpatient unit will document Using the Pressure ulcer Identification form and will flag for physician review and signature.

2.) The nurse will take a photograph of the pressure ulcers to include healed or scarred ulcers and place in the patient's medical record at the following times:

- As soon as possible when the patient is admitted or when pressure ulcer is discovered.

-Weekly, to assess response to treatment, every Sunday.

-When the patient is discharged or transferred to another level of care.

-When there is a significant change in status such as wound deterioration or a healed wound.

4.) Pressure ulcer assessments are completed and documented in the medical record at minimum every shift.

5.) Staff nurses document pressure ulcer interventions in medical record and the patient's response to interventions per plan of care.


D.) Section entitled: Management of pressure ulcers or patients "at risk" for pressure ulcers:

1.) The pressure ulcer prevention protocol is implemented for "at risk" patients. The pressure ulcer prevention protocol/ standing delegated order is utilized to implement the protocol. The orders are transcribed, the nurse initiating the orders signs it, and places it in the physician's orders section of the chart, flagged for physician signature, acknowledging the use of the protocol.

2.) Notify Physician for pressure ulcer management orders, Including Wound Care Nurse consult, as applicable. Encourage physician to utilize the applicable wound care order sets.

3.) Consult dietician for optimal wound healing or pressure ulcer prevention.

4.) Consult diabetes educator if applicable.

5.) Implement and document pressure ulcer prevention and/or treatment as ordered


In an interview conducted on 1/25/17 @ 12:15 pm, Registered Nurse (RN)-A revealed if a specialty bed is ordered for the patient, the intervention would be documented o the nursing daily assessment form under "Skin Interventions".


In an interview conducted on 1/25/17@ 12:30 pm, the facility Chief Nursing Officer (CNO) revealed that if nursing staff received orders for wound care on a Friday, the wound care nurse would not see the patient until the following Monday. Floor nursing staffs would be responsible for providing wound care on weekends. He also confirmed that a specialty mattress would be documented under daily nursing assessments "Skin Interventions".


In an interview conducted on 1/25/17 @ 1:15 pm, RN- B revealed that when a specialty mattress is ordered for a patient, nursing staff would fill out a green central supply requisition form to be sent to central supply personnel. The carbon copy would then be kept in the patient chart. When asked how long it normally took to receive the mattress from central supply, RN-A stated "It usually doesn't take that long." If not received nursing staff would call central supply to find out when the mattress would be available. During further interview, RN-A was asked about nursing protocol regarding wound care in the event a patient presents with wound needs on a weekend/ nights. She revealed that nursing staff would be responsible for calling the physician to obtain wound care orders and applying those orders for the patient because the wound care nurse is not available on weekends.


In an interview conducted on 1/25/17 @ 2:30 pm, the facility Risk Manager confirmed all of the above findings, and further revealed that the facility central supply had no documentation/ requisitions to show that Patient #1 ever received the specialty air mattress which the physician ordered on 5/03/16 before his subsequent discharge on 5/09/16.

Based on record reviews and interviews, the facility failed to ensure organized nursing services were provided in accordance with the needs of patients for 1 of 1 patients (#1) admitted to the facility. The facility failed to:


-Ensure Patient #1 received a specialized air mattress to treat/ prevent pressure ulcers as ordered by the physician, and


-Ensure the facility wound care nurse and/ or floor nursing staffs assessed and provided treatment of patient #1's pressure ulcers.


As a result, Patient #1 developed a secondary pressure ulcer on his scrotum and a possible worsening of an existing pressure ulcer on his left buttock during his stay in the facility. This deficient practice also had the potential to cause injury and/or harm to all patients receiving treatment in the facility.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Nursing Services.


Cross refer: A 0392

Based on record reviews and interviews, the facility failed to ensure that nursing services were provided to meet the needs of patients, in 1 of 1 patients (#1) admitted to the facility. The facility failed to:


-Ensure Patient #1 received a specialized air mattress to treat/ prevent pressure ulcers as ordered by the physician, and


-Ensure the facility wound care nurse and/ or floor nursing staffs assessed and provided treatment of patient #1's pressure ulcers.


As a result, Patient #1 developed a secondary pressure ulcer on his scrotum and a possible worsening of an existing pressure ulcer on his left buttock during his stay in the facility. This deficient practice also had the potential to cause injury and/or harm to all patients receiving treatment in the facility.


Findings include:


Record review of the clinical record for Patient #1 on 1/25/17 revealed that he was a 25 year old male who was admitted on 5/03/16 with diagnosis of Retrocardiac pneumonia, adrenal leukodystrophy, and protein calorie malnutrition. Further review revealed he was profoundly developmentally disabled and was bed bound with a history of pressure ulcers.


Review of the physician's orders for patient #1 revealed the following orders:


- 5/03/16 @ 8:25 pm : (Swift Orders) Air mattress/ bed or overlay due to pressure ulcers or high risk for developing one.

- 5/07/16 @ 10:00 am: Wound Care evaluation.

- 5/07/16 @10:00 am: Please obtain air mattress (second request).


Further review of the physician's orders revealed no evidence that orders were obtained for wound care for Patient #1's pressure ulcers prior to discharge on 5/09/17.


Record review of the nursing documentation revealed the following:


Form entitled: Pressure ulcer identification form, dated 5/03/16 @ 10:00 pm:

Two areas on the form were checked for pressure ulcer status and were as follows:

-Pressure ulcer present on admission (Yes) Left Buttock. Skin intact with non-blanchable redness and

- Pressure ulcer present on admission (Yes) Left buttock. Full thickness tissue loss subcutaneous fat may be visible but bone, muscle or tendon is not exposed.


Record review of the nursing assessments for Patient #1 reveled the following:

- Skin:

Skin interventions documented for 5/04/16- 5/06/16:

- Use barrier ointment
- Turn every 2 hours
- Heels off bed
- Heel check
- Redistribution of skin surface
- Condom catheter


Skin interventions documented for 5/07/16 @ 10:59 am - 5/08/16 @ 10:21 pm:

- Use barrier ointment
- Turn every 2 hours
- Heels off bed
- Heel check
- Redistribution of skin surface


On 5/04/16 @ 2:43, 5/07/16 @ 7:38 pm, and 5/08/16 @ 10:21 pm, "Specialty bed" was documented under interventions, but does not appear in subsequent documentation.

There was no documentation present for Saturday 5/07/16 @12:22 am- 10:00 am.


-Wound Documentation:

5/04/16 @ 2:43 am: (Wound 1) Buttock pressure ulcer, approximated redness, open epidermal, moist wound bed.

5/04/16 @ 7:31 am: (Wound 1) Buttock pressure ulcer, approximated redness, open epidermal, moist wound bed.

5/05/16 @ 7:23 am: (Wound 1) Buttock pressure ulcer, approximated redness, open epidermal, moist wound bed.

5/06/16 @ 3:03 am: (Wound 1) Buttock skin tear approximated redness. Community acquired: yes. Reddened, dry/scaly moist.

5/06/16 @ 2:23 pm: (Wound 1) pressure ulcer, approximated redness. Community acquired: yes. Reddened, Scant serosanguinous drainage, dressing dry and intact. Dressing type: dry gauze. Wound Consult.

5/06/16 @ 9:46 pm: (Wound 1) pressure ulcer, approximated redness. Community acquired: yes. Reddened, Scant serosanguinous drainage, dressing changed. Dressing type: dry gauze.

(On 5/07/16 (Saturday) a secondary wound is documented):

5/07/16@ 10:59 am: (Wound1) Buttock pressure ulcer, redness. Community acquired: yes. Reddened, serosanguinous drainage, dressing changed. Dressing type: dry gauze.

5/07/16@ 10:59 am: (Wound 2) Scrotal pressure ulcer. Redness non-blanchable. Cleaned, wound ointment applied.

5/07/16@ 7:38 pm: (Wound1) Buttock pressure ulcer, redness. Community acquired: yes. Reddened, serosanguinous drainage, dressing changed. Dressing dry and intact.

5/07/16@ 7:38 pm: (Wound 2) Scrotal pressure ulcer. Redness non-blanchable. Cleaned, wound ointment applied.

5/07/16@ 10:21 pm: (Wound1) Buttock pressure ulcer, redness. Community acquired: yes. Reddened, serosanguinous drainage, dressing changed. Dressing dry and intact.

5/07/16@ 10:21 pm: (Wound 2) Scrotal pressure ulcer. Redness non-blanchable. Cleaned, wound ointment applied.


Record review of the Photographic Wound documentation revealed that on 5/07/16 @ 11:50 am, Licensed Vocational Nurse (LVN)-A obtained photographic documentation of a pressure ulcer to Patient #1's left buttock which was approximately 4 inches in length and 3.5-4 inches in diameter. There is what appears to be a centralized area of black eschar and surrounding skin erythema. In addition, a secondary scrotal ulcer was also photographed which appeared to be open, with a moist, reddened wound bed. Scale is unable to be determined due to a lack of measurement tool in photographic documentation. There was no evidience that nursing staffs photographically documented Patient #1's pressure ulcers on admission.


Further review of the documentation revealed no evidence that the wound care nurse assessed or treated Patient #1 for his pressure ulcers before his discharge on 5/09/16. Also, there was no evidence of central supply requisitions/ documentation to show Patient #1 received a specialty air mattress.


Record review of the facility Policy entitled: Interdisciplinary Admission Assessment and Reassessment, Dated 08/2016 revealed in part the following:


M.) Wound Ostomy Nurse:

2.) Nursing staff notify the facility wound ostomy nurse and physician upon identification of a pressure ulcer, and wound care orders are obtained from the physician using facility order sets. Nursing staff utilize the pressure ulcer prevention standing delegated orders for high risk patients and patients with pressure ulcers.


Record review of the facility policy entitled: Guidelines for Identification, Prevention, and Management of Pressure ulcers, dated 09/2014 revealed in part the following:

C.) Section Entitled: Documentation of Pressure Ulcers:

1.) The nurse on the inpatient unit will document Using the Pressure ulcer Identification form and will flag for physician review and signature.

2.) The nurse will take a photograph of the pressure ulcers to include healed or scarred ulcers and place in the patient's medical record at the following times:

- As soon as possible when the patient is admitted or when pressure ulcer is discovered.

-Weekly, to assess response to treatment, every Sunday.

-When the patient is discharged or transferred to another level of care.

-When there is a significant change in status such as wound deterioration or a healed wound.

4.) Pressure ulcer assessments are completed and documented in the medical record at minimum every shift.

5.) Staff nurses document pressure ulcer interventions in medical record and the patient's response to interventions per plan of care.


D.) Section entitled: Management of pressure ulcers or patients "at risk" for pressure ulcers:

1.) The pressure ulcer prevention protocol is implemented for "at risk" patients. The pressure ulcer prevention protocol/ standing delegated order is utilized to implement the protocol. The orders are transcribed, the nurse initiating the orders signs it, and places it in the physician's orders section of the chart, flagged for physician signature, acknowledging the use of the protocol.

2.) Notify Physician for pressure ulcer management orders, Including Wound Care Nurse consult, as applicable. Encourage physician to utilize the applicable wound care order sets.

3.) Consult dietician for optimal wound healing or pressure ulcer prevention

4.) Consult diabetes educator if applicable.

5.) Implement and document pressure ulcer prevention and/or treatment as ordered.


In an interview conducted on 1/25/17 @ 12:15 pm, Registered Nurse (RN)-A revealed if a specialty bed is ordered for the patient, the intervention would be documented o the nursing daily assessment form under "Skin Interventions".


In an interview conducted on 1/25/17@ 12:30 pm, the facility Chief Nursing Officer (CNO) revealed that if nursing staff received orders for wound care on a Friday, the wound care nurse would not see the patient until the following Monday. Floor nursing staffs would be responsible for providing wound care on weekends. He also confirmed that a specialty mattress would be documented under daily nursing assessments "Skin Interventions".


In an interview conducted on 1/25/17 @ 1:15 pm, RN- B revealed that when a specialty mattress is ordered for a patient, nursing staff would fill out a green central supply requisition form to be sent to central supply personnel. The carbon copy would then be kept in the patient chart. When asked how long it normally took to receive the mattress from central supply, RN-A stated "It usually doesn't take that long." If not received nursing staff would call central supply to find out when the mattress would be available. During further interview, RN-A was asked about nursing protocol regarding wound care in the event a patient presents with wound needs on a weekend/ nights. She revealed that nursing staff would be responsible for calling the physician to obtain wound care orders and applying those orders for the patient because the wound care nurse is not available on weekends.


In an interview conducted on 1/25/17 @ 2:30 pm, the facility Risk Manager confirmed all of the above findings, and further revealed that the facility central supply had no documentation/ requisitions to show that Patient #1 ever received the specialty air mattress which the physician ordered on 5/03/16 before his subsequent discharge on 5/09/16.