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Based on review of the medical record, policies and procedures and staff interviews, the nursing staff failed to accurately document, monitor, and communicate with other disciplines regarding pressure ulcer findings for patient #1.

Per the hospital's pressure ulcer protocol, patient #1 had 6 of the 11 conditions which automatically placed her in the high risk category. Her conditions include immobility/inactivity, frail/elderly, incontinent, overweight, diabetes, and on immunosuppressive medications.

On 6/19/11, patient #1's skin was described as not intact and non-elastic. The specific detail describes fissure, bottom excoriation on the sacrum with Braden score of 15 or low risk. The evening assessment described the skin as not intact with tenting turgor, dusky color mucous membranes, fissure with excoriation bottom on the sacrum. The Braden risk score was changed to 11 or high risk. On 6/20/11 the skin was described as not intact, elastic, with pink mucous membranes; bruising on the abdomen and fissure with bottom excoriated sacral. At this time the patient's Braden scale was 16 or low risk. Just before discharge on 6/20/11 the patient's skin was described as dry, warm, not intact, and elastic skin turgor. The groin area was described as discoloration. The buttocks with erythema (redness or rash), non-blanchable. Further comment: small stage II ulcer, buttocks fold. The patient also had a fissure with bottom excoriation on the sacrum.

Review of the medical record revealed the changes in the patient skin were not reported to the physician, wound ostomy nurse, case management nor the patient's daughter to assure follow-up at discharge. Review of the every 12 hour nursing assessment forms, revealed the that Braden scores were inconsistent even when the patient had evidence of breakdown her scores were low risk. The patient had 6 out of 11 conditions per the pressure ulcer protocol that would place her at high risk for development of a pressure ulcer. Review of the nutrition consults revealed no lab work for protein or albumin levels (test used to diagnosis disease, a decrease could reflect protein deficiency and malnutrition) nor mention of patient skin after the initial assessment in which the skin was intact. Also review of the 24 hour Rounding Point of Care revealed that not only were there inconsistencies in documentation of the turning/reposition including the position such as lying on the back, left or right side. The medical record revealed extended period when the patient was lying on her back from 2 hours/45 minutes to 10 hours/14 minutes. The patient was lying on her back in all the examples for the length ot time identified as follows:
6/4/11 10:01 PM to 6/5/11 2:14 AM for total 4 hours/13 minutes.
6/6/11 12:05 AM to 6/6/11 6:06 AM for total 6 hours/1 minute.
6/9/11 2:00 AM to 6/9/11 8:57 AM for total 6 hours/57 minutes.
6/9/11 2:57 PM to 6/9/11 9:35 PM for total 6 hours/38 minutes.
6/10/11 12:27 AM to 6/10/11 8:16 AM for total 7 hours/49 minutes.

The patient was off the unit at 9:52 AM and returned on 12:02 PM
6/10/11 12:02 PM to 6/10/11 5:35 PM for total 5 hours/35 minutes.
6/14/11 7:15 AM to 6/14/11 5:29 PM for total 10 hours/14 minutes.
6/18/11 1:28 AM to 6/18/11 3:43 AM for total 2 hours/45 minutes.
6/19/11 12:14 AM to 6/19/11 4:16 AM for total 4 hours/2 minutes.
6/19/11 8:07 AM to 6/19/11 11:35 AM for total 3 hours/28 minutes.
6/19/11 1:32 PM to 6/19/11 7:54 PM for total 6 hours/22 minutes.

Per the pressure ulcer protocol, patients are turned and repositioned every 2 hours at minimum.

Based on review of patient #1's medical record revealed the following:
1. Patient #1 developed pressure ulcers after entering the hospital with intact skin except a healing ulcer on her right lower leg.
2. The pressure ulcers were not reported to the physician, wound ostomy nurse, dietician, case management, the patient's daughter nor documented on the patient's care plan.
3. The patient's discharge summary did not document the pressure ulcers and treatment.
4. No follow-up treatments were ordered for the patient once discharged to home.
5. The medical record revealed inconsistencies in documentation of Braden scores, and the 24 hour rounding forms revealed that the patient remained on her back for extended periods of time, up to 10 hours.

Based on policies and procedures and review of the medical record the hospital failed to ensure the the medical records were complete, accurate, and legible as required by Federal regulation and as evidenced by:

In 2 out of 9 medical record reviews (patient #2 and patient #4) the consultations were not signed as of the survey date 7/15/11.
Patient #2, 44 year old female admitted on 6/8/11 with altered mental status. The patient had a psychiatric consultation dictated on 6/9/11 but was not signed by the physician.
Patient #4, 31 year old who presented to the hospital after he fell and hit his head with development of seizures. The patient had a neurology consultation dictated on 6/5/11, but was not signed by the physician.

In 3 out of 9 medical record reviews (patient #1, #2 and #3) the telephone orders were not authenticated in a timely manner.
Patient #1, 80 year old female presented to ED with fever and SOB. Telephone order for 6/12/11 authenticated on 6/23/11.
Patient #2, 44 year old female admitted on 6/8/11 with altered mental status. Telephone orders for 6/12/11 authenticated on 6/21/11 and order for 6/14/11 authenticated on 6/19/11.
Patient #3, 63 year old male admitted to the hospital with chest/stomach pain and shortness of breath for 4 days. Telephone order dated 5/25/11, authenticated 5/29/11.

In 1 out of 9 medical record reviews (patient #3) the discharge summary was dictated on 5/25/11 but was not authenticated by the physician.

In 1 out of 9 medical record reviews (patient #1) the operative report was dictated on 6/10/11 but not signed until 7/1/11.

Based on review of the medical record of patient #1, it was determined the hospital failed to notify the physician and the patient's daughter about the development of a sacral pressure ulcer. The hospital failed to arrange for continuity of care at discharge.

Patient #2 is a 81 year old female who presented to Harbor Hospital for cough for 1 week and fever of 101 degrees. The patient was experiencing labored breathing with a temperature of 103 degrees the day prior to admission. Her past medical history includes hypertension, Type II diabetes, hyperlipidemia, superficial venous thrombosis, GERD, esophageal ulcer, multiple cerebral vascular accident, and G-tube for feeding. The patient is nonverbal status post CVA and has been dependent on her daughter for the past 8 years due to immobility. The physical examination was noticeable for a 3x2 cm healing sore on the right medial lower leg. Otherwise the patient's skin was described as intact and dry on admission.

Review of the medical record revealed that the patient developed a sacral pressure ulcer and several other open areas which were being treated by the nursing staff. The sacral ulcer was a stage II and present at discharge. The hospital failed to notify the physician of the development of the pressure ulcer. Therefore no mention of the sacral pressure ulcer could be found in the discharge summary. The hospital failed to communicate to the daughter regarding the sacral pressure ulcer nor did the hospital arrange for post-hospital care/treatment for the pressure ulcer. Per the discharge orders the patient was discharged home to the daughter without orders and services for wound care.