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Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #1) as evidenced by failure to ensure the patient's decubitus ulcer was measured and staged on admission (03/08/13). Review of the record revealed the patient's decubitus ulcer was not measured and staged until 03/17/13, nine (9) days after admission.

The findings include:

Review of the facility policy, "Fundamental Nursing Procedures", dated 07/20/12 revealed under the "Skin Integrity" section that licensed nurses should assess skin integrity upon admission and any time an event comprises the skin integrity of a patient. The policy indicated under this section that the Skin Assessment Flowsheet and the appropriate Personal Recovery Plan (PRP) if significant altered skin integrity was present. Further review under this section revealed patients were to be reassessed weekly utilizing the Skin Assessment Flowsheet.

Review of Patient #1's record revealed an admission date of 03/08/13, and diagnoses which included Paralysis from surgery related to a Motor Vehicle Accident; Mood Disorder, Severe Pain, and Decubitus Ulcer of the mid-right buttock. Review of the Advanced Practice Registered Nurse's (APRN's) admission assessment, dated 03/08/13 and timed 10:00 AM, revealed documentation which stated Patient #1 had a healing Decubitus Ulcer on his/her right buttock near an anal fissure. Review of the APRN's orders, dated 03/08/13 and timed 11:40 AM, revealed an order to clean the "wound" on the patient's right mid-buttock daily with Aloe Vesta cleansing foam and apply zinc oxide and cover with a soft cloth dressing until healed.

Review of the hospital Nursing Assessment, dated 03/08/13, revealed no documented evidence of a Decubitus Ulcer on Patient #1's right mid-buttock. Further review revealed no documented evidence of a Skin Assessment Flowsheet completed at the time of admission as per the facility policy. Continued review of the record revealed no documented evidence a Skin Assessment Flowsheet was initiated until 03/17/13, five (5) days after the patient's admission to the facility. Record review revealed no documented evidence of measurements or staging of the Decubitus Ulcer until 03/17/13. Review of the record revealed no documented evidence a PRP for altered skin integrity was initiated until 03/15/13, seven (7) days after admission.

Interview, on 04/03/13 at 1:40 PM, with Patient #1 revealed he was admitted to the facility with the Decubitus Ulcer on his/her right mid-buttock. He stated he couldn't see the area, however had been told it was improving.

Interview, on 04/03/13 at 3:30 PM, with Registered Nurse (RN) #3 revealed Patient #1 was admitted with the "healing" Decubitus Ulcer to his/her right mid-buttock.

Interview, on 04/05/13 at 1:33 PM, with the APRN, who performed the admission assessment, revealed Patient #1 was admitted with a Stage III healing Decubitus Ulcer. She stated she wrote the initial orders for treatment to the area.

Interview, on 04/08/13 at 3:10 PM, with RN #7 revealed nursing staff should have completed, on the patient's admission to the facility, a Skin Assessment form with measurements and staging . The RN stated she initiated the Skin Assessment form on 03/17/13 when she realized one hadn't been started as of yet. She stated a PRP should also have been initiated on admission.

Interview, on 04/05/13 at 11:50 AM, with the Unit Manager of the unit on which Patient #1 resided, revealed a Skin Assessment form with measurements and staging and PRP should have been initiated on admission related to the patient's Decubitus Ulcer. She stated this should have been done so the Decubitus Ulcer could be tracked for improvement or worsening.