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Based on a review of facility documentation and medical records (MR), and staff interviews (EMP), it was determined that the facility failed follow their written policy for pressure ulcer documentation for medical records reviewed (MR4, MR5, MR7 and MR12).
Findings include:
Review on August 10, 2017, at approximately 11:30 AM revealed, "... Prevention and Treatment of Pressure Ulcers ... 81:00 ..." dated October 2014, indicated, "... Policy It is the policy of Heritage Valley Health System nursing staff to promote skin integrity through the prevention of pressure ulcers and the treatment of existing pressure ulcers. ... The Braden Scale is used to determine a patient's risk for pressure ulcer development and is completed by the Professional Registered Nurse on admission to an inpatient unit and then daily ... Nursing Interventions/Management Plan 1. Assess and accurately document the wound. Note location, size, stage, wound bed, surrounding area, signs of infection tunneling Measure ulcer length, width and depth in cm weekly. Reassess - skin and particularly pressure ulcers should be reassessed every shift and as needed. ... Nursing Interventions/Management Plan 9. Assess and accurately document the wound. Note location, size, stage, wound bed, surrounding area, signs of infection, tunneling. Measure ulcer length, width and depth in cm weekly ..."

1. Review of MR4 on August 11, 2017, at approximately 1:00 PM revealed that the patient was admitted on April 14, 2017. A wound assessment revealed that the patient had a an unstable stage IV wound to the coccyx on April 15, 2017. There was no further wound assessment completed until April 25, 2017, when the size was documented as 20 cm x 20 cm's (centimeters). The size of the wound on admission could not be determined.

2. Review of MR5 on August 11, 2017, at approximately 1:00 PM revealed that the patient was admitted on April 25, 2017. A wound assessment on April 26, 2017, indicated that there was a coccyx stage II on admission. On April 26, 2017, it was documented that there was a stage III bilateral buttocks wound, a right hip wound and a left ankle wound. On April 28, there was a left and right stage I and II buttocks pressure wound documented. On April 29, 2017, four days after the discovery of the wounds, the bilateral buttocks wound was documented as .5 x 1 cm's in size.

3. Review of MR7 on August 11, 2017, at approximately 1:30 PM revealed that the patient was admitted on May 4, 2017. A wound assessment on May 5, 2017, indicated that there was a right stage II buttocks wound. On May 10, 2017, it was documented that there was a right buttocks wound and a right gluteal wound. On May 11, 2017, it was documented that the patient had a stage II coccyx wound, and on May 13, three open buttocks stage II wounds were documented. On May 14, 2017, the patient was discharged, and it was documented that there was a left stage II buttocks wound. None of the wounds were sized on admission or on discovery of the wounds.

During an interview on August 11, 2017, at approximately 11:30 AM EMP11 confirmed that wound measurements were not obtained when discovered for for MR4, MR5, and MR7.

4. Review of MR12 on August 11, 2017, at approximately 1:30 PM revealed that the patient was admitted to the facility on July 12, 2017, with a right buttocks wound. On July 15, 2017, documentation revealed the patient had a right buttocks wound and a left coccyx wound. The coccyx wound was documented on July 16, and July 17, 2017. On July 18, 2017, a coccyx wound was documented and sized as 10 X 5.5 cm's.

During an interview on August 14, 2017, at approximately 11:30 AM EMP12 confirmed that wound measurements were not obtained when discovered for MR12.

Based on review of facility documents, medical record review (MR), and staff interviews (EMP), it was determined that the facility failed to ensure sufficient content of clinical records accompanied four of six transferred patients (MR4, MR6, MR7, and MR10).

Review of a facility documented "Access to Heritage Valley Health System's Clinical Access Portal (CAP)" revised August 4, 2017, revealed, "The facilities listed below have secure access to Heritage Valley Health System's Clinical Access Portal (CAP). When making referrals, or discharging patients from a Heritage Valley Hospital to one of these facilities, only those portions of the patient record not viewable in CAP should be faxed and/ or sent with the patient ... OTH3 ... OTH4 ... OTH5 ... OTH6 ..."

1. Review of MR4 on August 14, 2017, at approximately 10:00 AM revealed that the patient was discharged from Heritage Valley Beaver to OTH5 on April 27, 2017. There was no evidence that discharge instructions accompanied the patient.

2. Review of MR6 on August 14, 2017, at approximately 10:00 AM revealed that the patient was discharged from Heritage Valley Beaver to OTH6 on May 8, 2017. There was no evidence that discharge instructions accompanied the patient.

3. Review of MR7 on August 14, 2017, at approximately 10:00 AM revealed that the patient was discharged from Heritage Valley Beaver to OTH5 on May 14, 2017. There was no evidence that discharge instructions accompanied the patient.

4. Review of MR10 on August 14, 2017, at approximately 10:00 AM revealed that the patient was discharged from Heritage Valley Beaver to OTH4 on June 18, 2017. There was no evidence that discharge instructions accompanied the patient.

During an interview on August 14, 2017, at approximately 10:00 AM, EMP12 indicated that the pieces of the record that are not viewable in CAP are discharge notes and discharge information.

During an interview on August 11, 2017, at approximately 1:00 PM, EMP11 confirmed that the records for MR4, MR6, MR7, and MR10 did not include documentation that the instructions or discharge information accompanied the patients to the receiving facilities.