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Based on record reviews, interview, and reviews of policies and procedures, it was determined the hospital does not have an effective governing body legally responsible for the conduct of the hospital as an institution as it relates to Conditions of Participation at 0385, and the Standard of A 0395.

The cumulative effect of this lack of oversight and systemic issues resulted in the Governing Body's inability to ensure the facility maintained the provision of quality health care in a safe environment and assured that the patients' right to quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

The findings include:

Based on record reviews and interviews, the facility failed to assure nursing services supervised, evaluated and provided accurate assessment and reassessment related to pressure sores for 1 (Patients #1) of 2 open and 1 closed clinical records reviewed. Nursing failed to notify the physician of and obtain clarifying orders for the "covering" on the patient's left foot and "dressing" on the patient's right foot from 12/16/10 through 12/19/10. They failed to notify the physician when the patient complained of a hematoma to the left foot. They failed to adequately assess and implement interventions in an effort to attempt to prevent the Stage I pressure ulcer from deteriorating to a Stage III pressure ulcer. (Refer to A395).

Based on clinical record reviews, interviews, and review of policies and procedures, it was determined the hospital does not have an effective organized Nursing Department that provides 24-hour services to maintain the health, safety, and well-being of the patients it serves as it relates to the Condition of Participation and Standards A0395.

The findings include:

Based on record reviews and interviews, the facility failed to assure nursing services supervised, evaluated and provided accurate assessment and reassessment related to pressure sores for 1 (Patient #1) of 2 open and 1 closed clinical records reviewed. Nursing failed to notify the physician of and obtain clarifying orders for the "covering" on the patient's left foot and "dressing" on the patient's right foot from 12/16/10 through 12/19/10. They failed to notify the physician when the patient complained of a hematoma to the left foot. They failed to adequately assess and implement interventions in an effort to attempt to prevent the Stage I pressure ulcer from deteriorating to a Stage III pressure ulcer. (Refer to A395).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure the provision of quality health care in a safe environment and assure the quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

Based on record review, interview, and review of policies and procedures for pressure ulcers, nursing failed to adequately supervise, implement interventions and evaluate the nursing care of 1 (Patient #1) of 3 sampled patients with pressure ulcers. This failure contributed to the development of a Stage III pressure sore to the patient's left heel.

The findings include:

Clinical record review on 1/20/11 revealed Patient #1 was transported to the Emergency Room on 12/16/10 and subsequently admitted to the hospital for abdominal fullness and shortness of breath.

Review of the hospital H&P (History and Physical) dictated on 12/23/10 revealed the patient was found to have a pleural effusion, congestive heart failure, possible pneumonia along with ascites (accumulation of fluid in the abdominal cavity). The patient is also known to have severe infragenicular bilateral lower extremity peripheral arterial disease.

Review of the Emergency Room physician orders dated 12/16/10 included bed rest with bathroom privileges and SCD's (sequential compression devices) for DVT (deep vein thrombosis) prophylaxis.

Review of the admission nursing assessment dated 12/17/10 at 1815 revealed the patient's right foot with a toe amputation and a dressing as "clean, dry and intact." This assessment defers to the pressure ulcer note for an assessment of the patient's left foot. There was no physician's order for the dressing to the right foot.

Review of the pressure ulcer note dated 12/17/10 describes a left heel pressure ulcer Stage I to the patient's left foot. The nurse documents a dressing on the foot as "clean, dry and intact" and under the comments section of the note, the nurse documents "(MD) has already addressed wound and daughter informed me that we leave the dressing on."

There were no physician's orders for the dressing on the left foot. There was no physician documentation ordering the nurse to "leave the dressing on." There was no documentation to support the size of the pressure ulcer to the left heel.

Review of integumentary assessment of the patient's left foot, by the nurse on 12/17/10 at 2000 revealed, "covered, cared by his pod (podiatrist) MD per pt." The nurse documents, "the patient does not give me clear explanations about his left foot wound...just says, I don't know."

The nurse failed to question the rationale or notify the physician of the "cover" on the patient's left foot for which there was no order. In addition, she failed to fully assess the condition of the patient's left foot as the patient could not provide an accurate explanation of his foot.

The nurse further documents the SCD's were "in order." They had not been applied to the patient's legs despite being ordered by the physician the day before.

Review of the physician orders for 12/17/10 include Adult Venous Thromboembolism Prophylaxis which included knee-high intermittent sequential compression devices, to be maintained continuously except for bathing, skin assessment or ambulation.

Review of the nursing documentation from 12/17/10 through 12/20/10 (4 days) revealed once the SCD's were obtained, there was no documentation whether the SCD's were applied to the patient's lower extremities and also documented episodes of the patient's refusal to wear the devices. Nursing failed to notify the physician of the patient's refusals to wear the devices.

Nursing documents on 12/18/10 at 0828 the patient's left foot is covered and cared for by his podiatrist, per the patient, and the patient can not give a clear description about his left foot wound.

At 0430 on 12/19/10, nursing documents the patient complained of bilateral foot pain and percocet was given. There was no assessment of the cause of the pain and at 1245 and at 1645, nursing documents the patient's pain is interfering with moving.

On 12/18/10 at 1950, 12/19/10 at 0800, 2016, and on 12/20/10 at 0725 nursing documents the patient's left foot is covered, "cared by his pod MD" and per patient, "hematoma." There was no investigation or assessment as to how the "hematoma" developed, or, the location of the "hematoma." There was no indication the physician was notified or documentation to support the physician was aware of a hematoma on the patient's left foot.

In addition to the left foot, nursing notes document from 12/17/10 through 12/20/10 the presence of a right foot dressing without specific physician's orders. Nursing failed to consult the physician for orders for or removal of the dressing so that the condition of the patient's right foot could be assessed.

Review of the podiatry consult dated 12/19/10 at 1200 revealed the patient with dried eschar on the dorsum central aspect of the right foot as well as around the posterior heel. Also noted was a small pre-ulcerative area on the sub1st metatarsal on the left foot with no significant sign of edema or drainage noted. It was not until 12/19/10 where physician's orders reflected a treatment to the patient's right foot; there were still no treatment orders for the left foot. Nursing failed to consult the physician related to the complaints of hematoma to the left foot and continued to document the left foot as "covered" without a physician's order.

On 12/20/10, a wound care consult was called in by the attending physician for a "left lower extremity wound." Review of the wound care physician's consult revealed the "patient complains of a wound on the left heel, in the left fourth and fifth toe, interdigital space." The physician documented the patient has a wound measuring approximately 1 x 0.5 cm on the left heel which is covered with yellow rubbery necrotic tissue. The patient has multiple ecchymoses of the foot, which "appear to be secondary to a tube-like grip type of sleeve that was wearing from his midfoot up to the lower calf. The physician diagnosed the wound as a Stage III left heel pressure ulcer."

On 12/20/10, the wound care physician ordered a "waffle boot" to the patient's left foot; however, there was no documentation to support the application of a "waffle" boot to the left foot from the time it was ordered through the patient's discharge of 12/30/10.

Review of the hospital policy and procedure for pressure ulcer assessment and treatment for an "adult" reveals the following: "Assessment: provide a comprehensive skin assessment of all patients identified with pressure ulcers, and to identify those at risk. Pressure Ulcer Assessment: Admission assessment must be performed on all patients entering the hospital and should include both the risk assessment (to evaluate risk of developing a pressure ulcer) and thorough skin assessment (to detect existing pressure ulcers)." Wound measuring is to be done on admission and weekly to include the depth, size and stage of the wound. Under "Documentation" guidelines include daily documentation including all interventions performed by staff to prevent pressure ulcers, especially site-specific support products, specialty beds and repositioning and any notification of the physician. If a pressure ulcer develops, it should immediately be documented, including stage, size, location, and interventions documented.

Interview with the Risk Manager on 1/20/11 at 3:00 p.m., confirmed no additional documentation to support the patient's "covering" to the left foot and dressing to the right foot was clarified by the physician and orders obtained. In addition, she confirmed there was no additional documentation to support ongoing assessments of the condition of the patient's left foot which ultimately contributed to the development of a necrotic area to his left heel.

Nursing failed to notify the physician of and obtain clarifying orders for the "covering" on the patient's left foot and "dressing" on the patient's right foot from 12/16/10 through 12/19/10. They failed to notify the physician when the patient complained of a hematoma to the left foot. They failed to adequately assess and implement interventions in an effort to attempt to prevent the Stage I pressure ulcer from deteriorating to a Stage III pressure ulcer.