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Based on interview and record review, the facility failed to ensure a uniform level of nursing care in the form of only inititiating wound care through physician orders, making accurate wound descriptions and re-evaluating ineffective wound prevention measures in one of six sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed. An Emergency Room (ER) note of 12/29/10 at 10:55 a.m. read: "Work called police after pt(patient) was a no show X 3 days. Last seen 3 days ago. Pt was found on floor in home". A nurse's note of 9:00 p.m. on 12/29/10 read: "Lg pressure sore to coccyx open w/red and purple area picture taken and Mepiplex placed on coccyx and barrier creams applied". Mepiplex is a dressing made from polyurethane foam. Physician orders for this dressing (or any other dressing through 1/10/11) were not in the medical record. A History & Physical, dictated on 12/29/10 at 11:12 p.m. read: "The patient has skin tears to the left side of her sacrum, left shoulder, and proximal left forearm". Regarding the use of the term "sacrum", this location was used predominantly in subsequent text of the medical record (with coccyx used to a lesser degree). Later text reveals that there was no evidence of separate and distinct coccyx and sacral wounds.

Skin risk interventions were set forth in nursing documentation of 12/30/10. They included: "Reposition Q2hrs and PRN" . Nurse's notes of 12/29/10 mentioned the application of Mepiplex to the coccyx/sacral site. Nures's notes of 1/3/11 mentioned the application of Duoderm to the coccyx/sacral site. Duoderm is a hydrocolloid (see below). Nurse's notes of 1/6/11 mentioned the application of "Sacral Tegraderm" to the coccyx/sacral site. Tegraderm is a transparent dressing. Nurse's notes of 1/7/11 mentioned the application of Hydrocolloid to the coccyx/sacral site. Hydrocolloids absorb wound liquid in the presence of wound exudates.

A nurse's note of 1/7/11 at 8:00 p.m. mentioned a "tear", "non-open" on the upper middle back. This description contradicts itself, as a tear constiutes a break in the skin. This site is later described as a pressure sore (see below).

There was no evidence of a re-evaluation of pressure sore or skin injury prevention interventions upon the discovery of this site. This was the first mention in the medical record of the Thoracic or upper back region.

A nurse's note of 1/7/11 at 7:52 p.m. read: "Dressings to back and sacral region intact". This wound was addressed by the physician on the following day. There was no evidence of a physician order for this site (including a dressing) up to this point in time. Nurse's notes of 1/8/11 mentioned the application of Duoderm to the coccyx/sacral site. A nurse's note on 1/8/11 read: "Checked 2 decubitus by Dr. ... as one on middle back and one on sacral area". A nurse's note on 1/8/11 mentioned that the "tear" on the upper back was covered.

A nurse's note on 1/8/11 mentioned the application of Mepiplex to the coccyx/sacral site.

Nurse's notes of 1/9/11 at 8:00 a.m. mentioned that the application of Mepiplex to the "tear" of the upper middle back. Nurse's notes of 1/10/11 at 8:00 a.m. mentioned the application of Mepiplex to the coccyx/sacral site. Progress notes addressed the wounds on 1/10/11.

A nurse's note on 1/11/11 mentioned the application of Mepiplex to the upper middle back (thoracic) site, which was described as an "ulcer" .

A physician consultation note, dictated on 1/9/11 read: "The patient has been noted to have wounds over the thoracic area of her spine, as well as a sacral wound. These have been cultured and have been growing Pseudomonas ". Also: "Over the patient's back she has two wounds, one in the thoracic area that appears to be a stage II ulcer. The wound in the sacral area is a stage III. There is no evidence of visible bone. There is no purulence at this time". Also: "She had been found to have wounds on her back that vary in stages between a stage II in the thoracic area to a stage III in the sacral area. Pseudomonas has been cultured in heavy growth from these wounds".

Physician orders of 1/11/11 read: "Sacral wound orders: Aquacel ... , ABD and ... change daily. ... Protect thoracic wound with: hydrogel, 4 X 4 secure with tape change every other day". These were the first physician orders for wound dressings of the sacral/coccyx and thoracic sites. All of the other applications of dressings as indicated in prior text were done without any physician orders. The use of various types of dressings as mentioned in the above nurses notes indicated a lack of consistency and coordination in the nursing-initiated approach.

An interview with the Quality Manager on 3/28/11 at approximately 5:00 p.m.confirmed the preceding information.