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Based on observation, review of medical records and documents, and staff interviews, it was determined that the facility failed to ensure that nursing care is provided to promote effective management and treatment of patient pressure ulcers. Specifically, nursing failed to: (a) comply with clinical practice standards for documentation of assessment and treatment of pressure ulcers; (b) provide treatment to pressure ulcers as prescribed by the physician; (c) ensure appropriate discharge plan for patient with pressure ulcer; and the facility (d) failed to provide written protocol for documentation of pressure ulcer assessment and treatment; and (e) failed to provide written protocols to govern the management of pressure ulcers.
This was found in four (4) of 17 medical records reviewed.



Findings:

Patient #1:
On 08/10/14, this 61 year old (y/o) male presented to the Emergency Department (ED) from a Group Home for evaluation of Fever and Hypotension (low blood pressure), and was admitted to the facility with Diagnoses of Urinary Tract Infection (UTI), Rhabdomyolysis (a condition in which damaged skeletal muscle tissue breaks down rapidly - breakdown products of damaged muscle cells are released into the bloodstream; some of these, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure) and Fever. History of present illness: chief complaint of fever, lack of appetite for one day (x 1 day); non-verbal; wheel chair bound; and cognitively impaired. The History and Physical Exam completed by the ED physician noted a Stage I decubitus, left buttocks, but there is no documentation that treatment was initiated.

Upon admission to the facility, the initial skin assessment completed by the Registered Nurse (RN) on 08/11/14 at 08:15, documented the presence of (a) Left Medial DTI (suspected Deep Tissue Injury), (b) Lower Gluteal, (c) Left Gluteal, (d) redness with pus like spots to right upper back. This assessment documented the presence of a DTI pressure ulcer, but description of the pressure ulcers on the Left and Lower Gluteal areas were not documented. In addition, a full description of the pressure ulcers was not provided as specified in the Clinical Practice Guidelines: PRESSURE ULCER, which states, "Perform wound assessment (e.g., size, shape, color, odor, presence of exudate, tissue type, signs of infection, signs of healing, presence of pain) on admission, weekly, with signs of deterioration / condition change and with each dressing change."

The documentation could also not validate that the Stage I decubitus, on the left buttocks that was documented by the ED physician, was also assessed by the RN on 08/11/14 and there is no additional assessment / documentation in the medical record pertaining to the "redness with pus like spots to right upper back."

On 08/15/14, approximately four (4) days after admission to the facility, the RNs document the presence of six (6) pressure ulcers and documented that these pressure ulcers were present on admission. The pressure ulcers were numbered and described as follows:
(1) Left gluteal, Stage II and Unstageable: Appearance: pink.
(1) Left lower gluteal, Unstageable: Appearance; white, clean.
(1) Medial Left Gluteal DTI (Date Initiated = 08/11/14 08:18)
(1) Right Hip, DTI: Appearance; purple, white.
(2) Left gluteal, Unstageable; Appearance; closed/resurfaced.
(3) Left gluteal, Unstageable: Appearance; white, pink, closed/resurfaced.

The documentation did not give a full description of the pressure ulcers, "e.g., size, shape, color, odor, presence of exudate, tissue type, signs of infection, signs of healing, presence of pain, "as specified in the facility's Clinical Practice Guidelines: PRESSURE ULCER. This pattern of documentation was noted throughout the medical record.

The documentation related to the treatment of the pressure ulcers from 08/11/14 to 08/15/14 stated: "(1) Medial Left Gluteal DTI, dressing dry and intact" and on 08/17/17, "Allevyn dressing applied to gluteal area and right hip." There is no other documentation regarding treatment during this period. Specifically, the dressing type to the DTI pressure ulcer is not documented and there is no documentation that: (a) treatment to all pressure ulcers were initiated timely, prior to 08/15/14; and (b) treatment to all pressure ulcers was provided 08/15/14 to 08/18/14. There is also no documentation to determine signs of deterioration or condition change to the Unstageable and DTI pressure ulcers; no documentation of a referral or collaboration with the interdisciplinary team to ensure appropriate treatment for the Unstageable and DTI pressure ulcers; and the facility does not have a protocol to govern the use of Allevyn for pressure ulcer treatment.

These findings were confirmed with Staff #1 on 10/1/14 at approximately 3:00 PM.

During an interview conducted on 09/30/14, at 3:20 PM, Staff #2, the Director of Performance and Informatics stated the management of pressure ulcers is documented in Site Manager and Daily Assessments in the Electronic Medical Record (EMC). Documentation in Site Manager should include the date, time, location of the pressure ulcer and parameters such as size, depth, appearance, wound treatment and staging. Measurement is documented weekly with a description of the wound. Daily assessments, every eight hour (q8hr) shift, is documented by the nurse, and should include: the condition of the skin as a whole, and documentation of dressing change. Dressing for Stage 3 and 4 pressure ulcers are prescribed by the physician, the nurse will initiate Allevyn dressing to Stage 1 and 2 pressure ulcers. The Allevyn dressing is documented dry and intact and this dressing is left on until it falls off. Staff #2 acknowledged there is no written protocol for the documentation of pressure ulcers and there is no written protocol governing the management / treatment that is to be chosen for each type of pressure ulcer.

At interview on 10/02/14 at 11:00 AM, Staff #3, Nurse Practioner -Wound Care Nurse, stated daily rounding for patients with pressure ulcers is conducted per unit and the RN documents rounding in the computer. Rounding is triggered by (two) computer generated reports and phone calls from the staff on the unit. However, Staff #3 admitted that patient's may not all be seen and there is no written protocol to determine the priority and or which patient should be seen. Staff #3 also stated the RN or manager on the unit is responsible for making referrals to the Wound Care Nurse, but there is no written protocol to govern such referrals.

Review of the facility's Pressure Ulcer Report, created 08/13/14 showed Patient #1 is listed for admission to the facility with a "gluteal, suspected deep tissue injury charted on 08/12/14." This patient was not seen by the Wound Care Nurse.

The patient was discharged from the facility on 08/18/14 and at the time of discharge, the documentation in the medical record indicates the presence of six (6) pressure ulcers: four (4) Unstageable pressure ulcers to the Gluteal area; 0ne (1) DTI pressure ulcer, Gluteal area and (1) DTI pressure ulcer, Right Hip. However, the Discharge Plan of Care does not document the presence of the pressure ulcers and there is no documented treatment plan.


Patient # 2:

Patient was admitted to the facility on 9/28/14 for management of Urinary Tract Infection. The Admission Assessment by the RN documents the presence of pressure ulcers: (1) Ulceration Left Ankle, (2) Pressure ulcer 1St Toe, Unstageable, (3) Bilateral Gluteal, Stage 1. The size of the pressure ulcers were first documented on 8/30/14 and there is no other documentation of wound description (e.g., size, shape, color, odor, presence of exudate, tissue type, signs of infection, signs of healing, presence of pain). Treatment to the 1St Toe, Unstageable pressure ulcer is documented on 9/30/14; "cleanse with soap and water" and there is no documented treatment to the Left Ankle Ulceration and the Stage 1 pressure ulcer.

At interview on 10/01/14 at approximately 11:35 AM, Staff #4 the assigned RN, stated the use of soap and water to the Unstageable area is appropriate and "nothing in particular" is used to treat the Stage 1 pressure ulcer. Staff #5, RN Manager, confirmed the use of soap and water stating "there is no open wound and it can be washed with soap and water unless otherwise prescribed."

Findings were confirmed with Staff #1, who was also present at the time of the above interview on 10/01/14.

During an interview on 10/02/14 at 11:00 AM, Staff #3 stated the management of the Unstageable pressure ulcer is dependent on the location, how stable, and presence of infection or drainage. The site will be maintained dry and intact and treatment as per MD recommendation. This patient was listed on the facility's Pressure Ulcer Report on 9/29/14 for presence of Stage 1 and Unstageable pressure ulcers on admission. However, this patient was not seen by Staff #3, Wound Care Nurse, and there is no documentation of a referral or collaboration with the interdisciplinary team to ensure appropriate treatment for the Unstageable pressure ulcer. Staff #3 stated, the RN is responsible to trigger a referral. Staff #3 also stated that training for the management of Unstageable was provide to the staff, however training material was not provided to the surveyor as requested.


Patient #3:

Patient was admitted to the facility 8/22/14 with a diagnosis; Decubitus Ulcer Hip. The Admission Nursing Assessment on 8/22/14, documents the presence of pressure ulcers: (1) Rt. Foot Stage 3, Dressing dry and intact, (2) Hip, Right, Stage 4, Moist dressing, (3) Sacral Spine, Stage 4, Dressing dry and intact. On 8/23/14, "Dressing dry and intact" is documented. The MD treatment order 8/22/14: Silverdiazine cream application, Topical q12h to wound Right Heel; Dakins solution 0.25% for Irrigation. There is no documentation or description of the pressure ulcers, "e.g., size, shape, color, odor, presence of exudate, tissue type, signs of infection, signs of healing, presence of pain" on admission and ongoing. There is also no documentation to indicate that treatment was provided to the pressure ulcers q12h as ordered by the physician, and there is no documentation to indicate treatment to the Right Hip pressure ulcer. The patient was discharged from the facility on 8/24/14.

Findings were confirmed with Staff #1 and Staff #3 at approximately 11:40 AM on 10/02/14.



Patient # 4

Patient was admitted to the facility 8/28/14 with a diagnosis; Pathological Hip Fracture. The Admission Assessment by the RN documents the presence of a Stage 2 pressure ulcer, Gluteal fold, 1 centimeter (cm) x 2 centimeter (cm) x 2 centimeter (cm). Assessment and treatment of the pressure ulcer was inconsistently documented during the period 8/28/14 to 9/30/13. The pressure ulcer size and drainage was documented on 8/28, 8/29, 8/30. 9/19 and 9/30/14, and Allevyn dressing was documented 9/01 to 9/14 and 9/30/14. The RNs did not "Perform wound assessment (e.g., size, shape, color, odor, presence of exudate, tissue type, signs of infection, signs of healing, presence of pain) on admission," and document Daily assessments, q8hr shift, to include the condition and documentation of dressing change.