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Based on review of documentation and interviews with facility staff, the facility failed to adequately assess and document the skin condition of patient #2 on admission and failed to notify the patient's physician to obtain orders for treatment of a stage III decubitus which was not in compliance with facility policy and resulted in delay of treatment.

The findings were:

The electronic medical record of patient #2 for dates of service 5/9-11/18 was reviewed with the assistance of staff #1 and 2. The review of the medical record of patient #2 revealed the following. The admission nursing assessment dated 5/9/18 reflected in part "Skin findings location: small bruises on arms and legs. Reported decub (decubitus) with dressing. Skin findings, bruises, excoriation; skin color pale; skin tugor elastic; skin moisture dry; skin temperature warm; comment, patient combative and confused." A nursing assessment dated 5/10/18 reflected in part "Skin findings location, buttocks; skin findings, round, skin color, pink, reddened, blanchable; skin texture thin; skin moisture moist; skin temperature warm; comment: decubitus to left side." An assess wound note dated 5/11/18 reflected in part "Wound location left buttocks; wound type acute decubitus; pressure ulcer staging III; wound appearance clean/dry, reddened, necrotic, muscle visible; wound bed color red; wound edema degree 1+ thumbprint <30 sec; surrounding tissue appearance pink, dry; wound drainage amount scant/trace; wound drainage description serous [wound length, width and depth fields blank]." There was no evidence in the record that pictures of the decubitus were taken and that the decubitus was reported to patient #2's attending physician or the family.

The facility policy entitled "Decubitus Ulcers Prevention and Care Of" dated 12/15 reflected in part "It is the policy of Comanche County Medical Center that all patients admitted to the Medical Surgical Unit shall receive a complete head to toe assessment, at which time a thorough examination of the skin will be done. The assessment of the care or treatment needs of the patient will be ongoing throughout the patient's hospital stay. Pressure sores will receive appropriate treatment with every effort undertaken to prevent formation. Pressure sores or decubitus are described as ...Stage III. Full thickness skin loss involves damage or necrosis for subcutaneous tissue that may extend down to but not through underlying fascia ...Pressure sore/decubitus medical treatment: At the first sign of pressure sore/decubitus: take initial pictures and as needed identify, date and obtain orders for medical treatment of the patient ...Call physician to report and for treatment orders ...educate patient, significant other and/or family on prevention and/or treatment ...Documentation: Use the skin flow record ...document the size, length and width, the depth and the exudates, amount, color and odor."

In an interview with the CNO, staff #2 on the morning of 10/9/18 in an office, staff #2 stated if the patient had a decubitus, it should have been staged on admission and fully documented. She stated if the skin breakdown had been bad, it should have been reported to the doctor.

Based on review of documentation and interviews with facility staff, the facility failed to ensure that physician progress notes were recorded daily on acute care patients as required by medical staff rules and regulations as there were no physician progress notes recorded for a four day period in the medical record of patient #2 resulting in an incomplete record.

The findings were:

The electronic medical record of patient #2 for dates of service 3/23-30/18 was reviewed with the assistance of staff #1 and 2. The review of the medical record of patient #2 revealed that the record did not contain physician progress notes on 3/26-29/18.

The facility document entitled "Rules and Regulations of the Organized Medical Staff" dated 1/11 reflected in part "B.1.9.3. Progress notes shall be recorded at least daily on acute care patients. Notes shall be of an extemporaneous nature and cover significant diagnosis, other patient problems, events, complications and treatments, and provide a comprehensive record in the event of transfer of responsibility of care."

In an interview with the health information management director, staff #1 on the morning of 10/9/18 in an office, staff #1 stated that physician progress notes should be done daily. Staff #1 confirmed that patient #2 was in acute care from 3/23-30/18 and that no physician progress notes for 3/26-29/18 could be found in the medical record of patient #2.