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Based on review of documentation, interviews and review of the Hospital's internal investigation regarding Patient #1's stage III pressure ulcer the Hospital had not identified that nursing staff consistently followed Hospital polices and procedures related to prevention of pressure ulcers and that the descriptions of the pressure ulcer were inconsistent. Also, the Hospital had not developed/implemented an effective corrective action plan for the identified two pressure ulcers that were not assessed according to Hospital policies and procedures.

Findings included:

1) The Risk Manager was interviewed intermittently during the on-site investigation and the Hospital investigation regarding Patient #1's stage III pressure ulcer was reviewed. There was no corrective action plan.

2) The Hospital's policies/procedures related to skin/wound management stated that a Braden Risk Assessment Scale (evaluation of individual risk factors for breakdown) will be completed on admission, every 48 hours and when there is a major change in the patient's condition, when transferred from one floor to another and after an invasive or diagnostic procedure. A Braden Score of 18 or less is considered at risk for developing pressure ulcers. The Wound/Ostomy Nurse is consulted for all non-healing Stage II ulcers, Stage III, IV, DTI, and unstagable pressure ulcers. In the event pressure ulcers develop, the nursing staff will also measure the wound on the longest length, width and depth; a staff nurse will consult for assistance in staging the pressure ulcers as needed.

3) Review of Patient #1's medical record indicated the Patient was admitted on 8/18/10 for knee surgery. Patient #1's medical record indicated a Braden Score was not assessed on 8/27/10, 8/28/10, 8/29/10, 8/30/10, 8/31/10, 9/1/10, 9/2/10 as required by hospital policy. The spaces provided on Patient #1's Intensive Care Unit Flow Sheets were blank Patient did not receive a Braden Assessment score every 48 hours

4) Documentation dated 9/4/10 at 3:40 PM indicated Patient #1 was assessed to have a small healing coccyx ulcer that measured 1/2 centimeter (cm) x 1/2 cm. Patient #1 was turned and repositioned.

5) Documentation dated 9/6/10 at 10:57 PM indicated Patient #1 had no pressure ulcers.

6) Documentation dated 9/7/10 at 5:05 PM indicated Patient #1 had two coccyx ulcers.

7) Documentation dated 9/9/10 at 2 :37 PM indicated one stage III pressure ulcer and the the recommended tratement was Critic Aid. However documentation on 9/10/10 and 9/10/10 indicated the dressing on Patient's #1's coccyx was intact.

8) An assessment documented at 11:29 PM indicated the skin on the Patient's coccyx was intact.