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Based upon interview and record review, the facility failed to provide nursing care (adequate wound care) in sampled patient (SP#1), and (turning and repositioning) in (SP) #13, two of five (5) sampled patients .

The findings include:

1. Review of SP#1 closed medical record on 07/15/14 and 07/16/14 show that the patient was admitted to the facility on 05//27/14 chest pain and shortness of breath. The Interdisciplinary Plan of Care show that on 06/05/14 and 06/10/14, the patient had a left buttock open blister. Sacrum Protection documentation on 06/07/14 shows that the patient has redness to the sacrum and dressing was placed. Nursing Note on 06/15/14 at 10:30 am states that wound care was done with the Wound Care Nurse and that " triple antibiotic and honey was placed on mepilex and covered open skin tears on sacrum. The record did not document the staging of the wound to the sacrum.

Review of the Physician Discharge Order on 06/17/14 at 2:59 pm states, "please arrange for patient to have home health care services for assistance with medications, physical therapy for gait strengthening/return to previous function, BP (blood pressure) reading.

Review of Discharge Instructions shows that the patient was discharged home with family on 06/17/14 at 4:46 pm.

Review of Discharge Instructions did not show any education or prescriptions for wound care was provided to the patient and there was no wound orders or wound care information provided to the HHC provider at the time of discharge.

Review of the " Medical certification For Nursing Facility/Home- And Community- Based Services Form dated 06/16/2014 revealed there is no mention of wound care under (H) treatment and equipment needs, and the skin condition was left blank.


Review of the patient ' s Case Management Discharge Planning Notes on 06/20/14 state that Case Manager received call from the (named ) Provider HHC. Pt (patient) needs orders for wound care. Case Manager spoke with [name of MD]. Case Manager faxed doctor ' s orders to the Provider. Review of the Patient ' medical record shows that a prescription was written for the patient was dated 06/20/14 ( 2 days after discharge ) which note, Home Health Care-wound care please apply thera honey ointment and bactroban to sacral wound and change dressings daily.

Case Management Discharge Planning Notes on 06/23/14 show that a call from the patient ' s wife was received by the Case Manager. According to Case Management Discharge Planning Notes on 06/23/14, the patient ' s wife said the HHC agency don ' t have the wound care orders. CM (Case Manager) notes states that faxed wound care orders last Friday and I have fax confirmation. CM re-faxed orders to HHC Provider and spoke with [name of representative] and explained the situation. Case Management Discharge Planning Notes on 06/24/14 show that the Case Manager received another call from the patient ' s wife who stated that the HHC needs medications for wound care. The Case Manager spoke with [name of HHC representative] who will provide the medication

In an interview with the Nurse Manager of 7 South on 07/16/14 at 11:50am, she stated, " after going home, the family called concerned about wound care. " On 07/16/14 at 3:27pm, the Nurse Manager stated, " instructions for wounds are given in the Discharge Instructions. Wound Care instructions are given to patients who go to other facilities, even to facilities to which they came from with wounds. "



2. Sampled patient (SP) #13 was observed on 07/15/14 at 1:45 PM, on 7 North. The patient was sitting in a recliner with a cushion on the seat. SP#13 was interviewed in the presence of the Nursing Director of 7 North and the Manager of Accreditation Services.

In an interview with SP #13 on 07/15/14 at 1:45 PM the patient states, I have a wound on my butt. I got the wound in the ICU from sitting in a chair from 8:00 AM to 5:00 PM without turning. The nurses did not turn me and there was no cushion on the chair.


Review of SP #13 was medical record on 07/15/14 and 07/16/14 show that the patient was admitted to the facility on 07/11/14. Review of the patient ' s medical record shows that the patient underwent bypass surgery on 07/11/14 and was transferred to the Intensive Care Unit (ICU) afterwards.

Review of the patient ' s Daily Cares/Safety documentation show that on 07/12/14 there was no repositioning documented for the patient on 07/12/14 from 8am to 8pm.


Review of the facility ' s Skin Care Assessment and Guidelines for Skin Breakdown Prevention and Treatment states, " Patients who spend more than 4 hours in a chair and are considered Moderate to high risk or have signs of coccyx ischial breakdown should be placed on a pressure-redistribution device.
a. Reposition chair bound patients every hour.
b. Instruct patient/caregiver to shift weight every 15 minutes, if possible.

Based upon interview and record review, the facility failed to ensure the necessary medical information (wound care instructions) are provided to the appropriate agencies, as needed, for follow-up or ancillary care in 1(one) out of 12 sampled patients (SP)#1.


The findings include:

Review of SP#1 closed medical record on 07/15/14 and 07/16/14 show that the patient was admitted to the facility on 05//27/14 chest pain and shortness of breath. The Interdisciplinary Plan of Care shows that on 06/05/14 and 06/10/14, the patient had a left buttock open blister. The Sacrum Protection documentation on 06/07/14 shows that the patient has redness to the sacrum and dressing was placed. Nursing Note on 06/15/14 at 10:30 am states that wound care was done with the Wound Care Nurse and that " triple antibiotic and honey was placed on mepilex and covered open skin tears on sacrum.

Review of the Physician Discharge Order on 06/17/14 at 2:59 pm states, "please arrange for patient to have home health care services for assistance with medications, physical therapy for gait strengthening/return to previous function, BP (blood pressure) reading. The Case Management Discharge Planning Note on 06/17/14 at 3:18 pm states, " Case Manager received MD (medical doctor) orders to discharge the patient home with HHC and walker. Case Management Discharge Planning Note on 06/17/14 at 3:34 pm shows that the Case Manager faxed the orders to the Home Health Care Provider.

Review of Discharge Instructions shows that the patient was discharged home with family on 06/17/14 at 4:46 pm. The Discharge Instructions Home Health services for assistance with medications, physical therapy for gait strengthening /return to previous function, BP (blood pressure) reads.
Review of the " Medical certification For Nursing Facility/Home- And Community- Based Services Form dated 06/16/2014 revealed there is no mention of wound care under (H) treatment and equipment needs, and the skin condition was left blank.


Review of Discharge Instructions did not show that any education or prescriptions for wound care was provided to the patient or the HHC provider at discharge.

Review of the patient ' s Case Management Discharge Planning Notes on 06/20/14 state that Case Manager received call from Home Health Care Provider (HHC). Pt (patient) needs orders for wound care. Case Manager spoke with [name of MD]. Case Manager faxed the doctor ' s orders to HHC Provider. Review of the Patient ' medical record shows that a prescription was written for the patient was dated 06/20/14 ( 2 days after discharge ) which note, Home Health Care-wound care please apply Thera honey ointment and Bactroban to sacral wound and change dressings daily.

Case Management Discharge Planning Notes on 06/23/14 show that a call from the patient ' s wife was received by the Case Manager. According to Case Management Discharge Planning Notes on 06/23/14, the patient ' s wife said the HHC agency don ' t have the wound care orders. CM (Case Manager) notes states that faxed wound care orders last Friday and I have fax confirmation. CM re-faxed orders to HHC Provider and spoke with [name of representative] and explained the situation. Case Management Discharge Planning Notes on 06/24/14 show that the Case Manager received another call from the patient ' s wife who stated that the HHC needs medications for wound care. The Case Manager spoke with [name of HHC representative] who will provide the medications.


In an interview with the Case Manager ( #H ) on 07/16/14 at 11:50am he stated, the patient went home with home health for physical therapy and wound. When the patient was being discharged, I asked the doctor if he wanted to order wound care and he said no because the foot wound was healed on discharge. The doctor thought the wound was for the foot. I spoke with the wife prior to discharge. I did not speak with the family about discharge planning.


In an interview with the Nurse Manager of 7 South on 07/16/14 at 11:50 am, she stated, after going home, the family called concerned about wound care.

On 07/16/14 at 3:27 pm, the Nurse Manager then stated that the instructions for wounds are given in the Discharge Instructions. Wound Care instructions are given to patients who go to other facilities, even to facilities to which they came from with wounds.

In an interview with the Director of Care Management on 07/16/14 at 2:33 pm, she stated, if the family is here, we involve them in the discharge planning process. We would also involve the family, if the patient requests the family to be involved.


Review of the Facility ' s Discharge Policy has that prior to discharge the Case Manager evaluates each patient for discharge planning needs Home Care and other needed community resources.

Review of the facility ' s Discharge Planning Policy also state that all patients will be reassessed as their medical condition changes or when new discharge planning needs are identified and/or requested by the patient, family, physician, nurse, care manager, social worker, or community agency. These changes/updates will be communicated to the patient/family and documented ( in the facility management system). This note will be included in the patient ' s medical record by the Care Management department.