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Based on observations, interviews and documents review, it was determined that the deficient practices found posed an Immediate Jeopardy to the health and safety of patients that caused harm, likelihood of harm, serious injury and possibly death.



Based on observations, interviews, review of clinical records, policies and clinical practice guidelines, it was determined that the facility failed to assure that patient care needs were met to prevent injury and harm. The facility failed to assess and document the size and stage of pressures ulcers of patients per facility Clinical Practice Guidelines; failed to implement the plan of care and reassess the patient's nursing care needs and response to treatment which resluted in harm for Patient #7 and #4. See Tag A 0395, Tag A 0396.


Based on observations, interviews, review of clinical records, policies and clinical practice guidelines, it was determined the facility failed to assess and document the size and stage of pressures ulcers of patients per facility Clinical Practice Guidelines. Patient care needs and response to interventions could not be evaluated from the clinical records reviewed. The failed practice resulted in harm to Patient #7 and #4, and potential harm to Patient #5, and affects all patients admitted to the facility. See Tag A 0395


Based on observations, interviews and clinical records review, it was determined that the facility failed to implement the plan of care and reassess the patient's nursing care needs and response to nursing interventions for Patient # 7. The failed practice resulted in actual harm to Patient #7 and had the likelihood to affect all patients in the facility. See Tag A 0396

Based on observations, interviews, review of clinical records, policies and Clinical Practice Guidelines, it was determined that the Facility failed to assess and document the size and stage of pressure ulcers per facility Clinical Practice Guidelines. Patient care needs and response to interventions could not be evaluated based on the cloinical records reviewed. The failed practice resulted in harm to Patient #7 and #4 and a likelihoon of harm to Patient #5 and all patients admitted to the facility.

The findings were:

A. Observation on 01/24/14, at 1220, with RN #2 and Director #2 revealed two open areas along her spine, mid and lower back on Patient #7. RN #2 stated Patient #7 did not have additional breakdown. Surveyor requested to visualize Patient #7's heels. RN #2 picked up the left heel and stated, "it's just bruised". Surveyor informed RN #2 the area on the heel had a blister. When asked how it would be described, RN #2 stated it was a "Stage I" then stated, "It's probably a Stage II, and stated it was "one-half dollar size blister and the heel was soft." RN #2 confirmed at the time of observation she was not aware of the blister prior to observation with the Surveyor.


B. Patient #7's clinical record was reviewed with Director #2 on 01/24/14 and revealed the following:

1) There was no documentation of a decubitus to the left heel. Patient #7 was admitted to the Facility on 01/17/14. The Admission Nursing Assessment, documented 01/17/14, at 0811 AM, revealed a female patient with height listed as 5 feet 7 inches and weight was listed as 90 pounds. Albumin was 2.2 per dietary care plan. Eyes open to pain, no verbal response. Motor response "localizes Pain. Level of Consciousness was "Responds to Voice, pain. Unable to assess orientation and speech unintelligible." The Integumentary (skin) status was listed as "warm, dry, oral mucosa moist, pink, turgor good and skin color normal for race. The Braden Skin Assessment was occasionally moist and slightly limited sensory perception. Activity is bedfast, mobility was very limited and nutrition probably inadequate friction and sheer was listed as a problem. The total Braden score was 12, which corresponds to High Risk per Facility score.


2) The admission skin assessment for 01/17/14 revealed: "Wound/Incision present upon admission "yes". The area was listed as "midline, lower back and pressure ulcer. Pressure ulcer stage: "Suspected Deep Tissue Injury, fusia (sic) in color, non-blanchable. Approximately 1.5 inches x 1.5 inches in diameter." Another area of skin impairment was listed as "midline back" "superficial wound that blanches". The wound appearance stated, "superficial and the type was abrasion, approximately 1 centimeter x 1 centimeter with eschar noted".

3) The Wound/Incision Assessment for 01/18/14, at 1430, revealed: Midline, lower back: Wound type was rash, pink, dry and pale. The area of Midline lower back listed "Pressure Ulcer, no change, no drainage". The surrounding tissue was listed as clean, dry and intact. The dressing type was Mepilex Dressing, moist. The Midline back: Pressure Ulcer, no change, dry, color was bright red. The surrounding tissue and appearance was listed as clean, dry intact with a Mepilex Dressing. The left Hip was listed as an incision. No change in appearance, clean, staples intact. No drainage, dry and open to air."

4) The Wound/Incision Assessment for 01/19/14 at 1000 was listed as "not done".

5) The Wound/Incision Assessment for 01/19/14 at 2200 listed: Midline, lower back: Pressure Ulcer, pink, wound appearance is no change, color is pink and dry. The dressing appearance: clean, dry intact and covered with Mepilex dressing. The Midline back: wound type is listed as pressure ulcer, no change in appearance, clean dry intact covered with Mepilex dressing. The left hip: wound type is incision, no change with wound appearance as "well approximated, clean staples intact, no drainage and open to air".

6) The wound assessment for 01/20/14 at 1000 and 2200 was listed as "not done".

7) The Wound/Incision Assessment for 01/21/14 at 1000: Midline, lower back: Pressure ulcer: No change, dry, with the Mepilex dressing clean, dry and intact. The Midline back: wound type is listed as Pressure Ulcer, no change in appearance, area dry and intact with Mepilex dressing. The left hip: wound type is incision, no change with wound appearance as "well approximated, clean staples intact, open to air".

8) The Wound/Incision Assessment for 01/21/14 at 2200: Midline, lower back: Pressure Ulcer, the appearance was "well approximated". Dry, clean, intact with Mepilex Dressing. The Midline Back: wound type as pressure ulcer. Wound appearance is "no changes, well approximated, dry clean, dressing appearance is clean dry, intact foam". The Left hip: Wound type is incision. The wound appearance is listed as well approximated, clean, staples intact.

9) The Wound/Incision Assessment for 01/22/14 at 1000: Midline, lower back: Pressure Ulcer, no change, well approximated, dry, clean intact, foam dressing. The Midline back: wound type is listed as Pressure Ulcer, no change in appearance. Wound appearance is "Well approximated, clean, dry, intact, foam dressing. The Left hip: wound type is incision, no change. Well approximated, clean staples intact, no drainage. Dressing type is other.

10) The Wound/Incision Assessment for 01/22/14 at 2200: Midline, lower back: pressure Ulcer, clean dry intact Mepilex dressing. The Midline Back: wound type is Pressure Ulcer, dressing clean, dry, intact, Mepilex dressing. The left hip: Wound type is incision; wound appearance is o change well approximated, clean, staples intact, no dressing/open to air.

11) The Wound/Incision Assessment for 01/23/14 at 1000: midline, lower back only: The type was incision, clean with staples intact.

12) The Wound Incision Assessment for 01/23/14 at 2200 (recorded on 01/24/14 at 0800):
Midline, lower: "Mepilex dressing removed. Appears to be bruising." Midline back: Wound type is Pressure Ulcer. The Pressure Ulcer Stage is "Stage 3". The wound appearance is open, moist with small amount of white, yellow draining. The dressing appearance is moist, soiled. The dressing type is Mepilex dressing. Type of off loading is low-air loss mattress, pillows, turn. The Left hip wound type is Incision. The wound appearance is no change, well approximated, clean, and staples intact. No wound drainage and no dressing/Open to air.

13) The narrative nursing notes revealed:

01/17/14 at 2228 "...staples to left hip clean and intact."

01/18/14 at 0417: "patient asleep in bed. Unresponsive to verbal stimuli. Responds with moans to painful stimuli. No acute changes during this shift."

01/18/14 at 0548 "lab called lab alert for patient HGB 5.4/HCT 17.0. Spoke with (physicians) orders to type and cross for 1 unit PRBC and transfuse now, draw HH 1 hour after."

01/18/14 at 1759: "Pt. resting with eyes closed. Minimal responsiveness noted at present time. Moans occasionally."

01/18/14 at 2231: Patient in bed, unresponsive to verbal stimulation. Patient responds to pain and movement with moaning and eyes opening ...staples to left hip dry and intact with bruising. Mepilex to spinal processes."

01/19/14 at 2345: Patient resting in bed. Patient responded to verbal stimuli with eye opening and lip movement. Unable to grasp object or follow commands at this time."

01/20/14 at 1034: (case manager note) "...Kin air bed ordered..."

01/21/14 at 0731: The patient is resting in a kin air bed.

01/21/14 at 0800: Patient resting in bed with eyes open. Patient is on Kin air bed for risk of skin impairment due to immobility status. Patient is awake and alert but not oriented to person, place or time.

01/21/14 at 1810: "The kinair bed is low and locked with the bed rails up."

01/22/14 at 0434: "Pt. constantly calls out, but doesn't really know what she wants."

01/22/14 at 1618: disoriented to time and place, does not answer questions appropriately, states her feet are frozen, she states she is dead or dying, assured patient that her feet are not frozen and she is not dead ...turned and repositioned."

01/24/14 at 0754: "Pt. resting in Kin Air bed with eyes closed ...SCDs in place."


14) Review of the Plan of Care revealed the problem "Impaired Skin Integrity" with the outcome "absence of infection, skin integrity intact." The interventions listed included "bridge heels off bed. Use Pressure dispersing mattress, pressure relieving and avoid shearing."

15) Review of the physician orders revealed:

1/18/14 at 0830 "Kin-Air Bed"

01/21/14 "OOB (out of bed) bid (two times daily).

01/21/14 at 1500 "Consult PT to get OOB bid".

01/24/14 1330 "d/c (Discharge) to N.H. (nursing home). Skin Care consult".


16) Review of the physician progress notes revealed:

01/17/14 at 0840 (Admission): "PE (physical exam): Lethargic, Opens eyes to verbal commands. Appears frail, Extremities: Pitting edema lower extremities, right (greater than sign) left. Left foot with large hematoma below knee."

01/24/14 at 1000: "Extremities- has bruising to top of left foot."


17) The findings were confirmed simultaneously with clinical record review. For 01/18/14 through 01/24/14 at 1230, the clinical record for Patient #7 lacked documentation of the stage of the pressure ulcers or measurements of identified pressure ulcers on the patient's mid back/spine area.


C. The facility Wound Care policy and procedure and Clinical Practice Guideline for "Pressure Ulcer Prevention and Treatment" was reviewed on 01/24/14 and revealed:

1) The purpose was listed as, "to provide guidelines and interventions for the nursing staff to assist in the prevention and treatment of pressure ulcers." The "Policy Statement" is "The Braden score is assessed on admission and daily on all inpatients. All pressure ulcers shall be documented in the medical record." A pressure ulcer is defined as "any lesion over a bony prominence resulting in damage of the underlying tissue. Pressure ulcers are staged to classify the degree of tissue damage." The Braden Scale is a tool for predicting a patient's pressure ulcer risk. The scale lists and assigns a score for each of the following subcategories: sensory perception, moisture, activity, mobility, nutrition, friction and shear."

2) The Procedures included: "Assess the patient's skin on admission and every shift. If a patient has a pressure ulcer, assess and document the stage and treat per physician's orders. Document the Braden Score on admission and daily.

3) Patient #7 had of Braden score of 12 on admission, which would place her in the High Risk category. The High Risk interventions included turning every two hours, utilize small, frequent position changes, offload heels with pillow beneath calves, provide appropriate pressure reduction support surface."

4) The Guidelines and tips included the statement of common sites included the skin over the vertebrae, scapulae, elbows, knees and heels in bedridden and relatively immobile patients.

5) The interventions stated, "Monitor high risk areas such as elbows, heels, sacrum and use pillows to reduce pressure over bony prominences. Place pillows longitudinally underneath calves with the heels suspended in the air."

6) The documentation stated "document any pressure ulcers including: location, stage of pressure ulcer, size, amount, color and odor of drainage if any, depth of undermining or tunneling if any and treatment provided. Document and update the care plan as needed. Document when the doctor was notified of pertinent abnormal observations."


D. An Interview was conducted with the Nurse Executive on 01/24/14 at 1430. The Nurse Executive provided the Pressure Ulcer Prevention and Treatment Clinical Practice Guideline. By interview, it was confirmed that the facility has skin care resources available to all employees on any computer within the system, via their intranet. All staff has the ability to access products to be used, positioning and documentation. This has been available for approximately 5 - 6 years. Specific training related to wound vacs and related documentation was provided in 01/2013 and 05/2013.

Patient #4

A) Patient #4's clinical record was reviewed on 01/23/14, and revealed the following:

The patient was admitted on 01/03/14 and discharged on 01/13/14. The admission physician orders, 01/03/14 at 1730 for "consult Wound Care Nurse - sacral decubitus". On 01/06/14 at 1415 a telephone order was noted for Mepilex foam to right buttock; change every 48 hours and as needed." On 01/11/14 at 1500 Wound care consult "pressure ulcers to heels".


B) The Wound care nurse progress note for 01/13/14 revealed "Stage II buttock almost healed. Bilateral heels with blisters: Right 2 x 3 cm burst; pink/moist with (less than) one cm black crater. Left 2 x 3 cm blister intact - clear fluid filled. neither heel looks infected. Will offload and use Betadine to draw out fluid and prevent infection. Would recommend follow-up".


C) Review of the Nursing narrative notes: 01/06/14:

01/06/14 1233 "decube wound care consulted".

01/08/14 0805 "repositioned patient as requested".

01/07/14 1055 "physical therapy to ambulate bid".

01/11/14 1450 "Brought to the attention of this nurse, state of patient's heels. Right heel presenting with oval pressure ulcer, unstageable, bed of necrotic tissue. Left heel has fluid filled vesicle present in same location, suspected deep tissue injury related to pressure. Doctor notified at this time to obtain wound care consult."


D) The admission nursing assessment 01/03/14 at 2030 revealed "Integumentary skin status warm, dry, oral mucosa moist, pink, turgor good. Skin color normal for race. skin comment: one cm round area to left buttock; dark red in color, no break in skin. Right buttock with 1.5 cm long Stage II." The Braden Score was 19.

1) On 01/06/14 at 2200 Left buttock is documented as clean dry intact Mepilex dressing "wound looks more like bruising".

2) 01/07/14 at 1000 Left buttock and right buttocks was documented as no changed , clean dry intact, dressing intact, Mepilex Dressing.

3) 01/07/14 at 2200 Left buttock document as pressure ulcer, no change in appearance, Stage II documented.

3) On 01/08/14 - 01/10/14 at 1000 and 2200, a Stage II pressure Ulcer is documented to the left buttocks.

4) On 01/11/14 at 2200 Wound assessment revealed left heel pressure ulcer with Stage listed as "suspected deep tissue injury, blisters" and right heel is pressure ulcer, non-stageable with wound appearance as eschar and partial thickness black necrosis amount as 26-50%" Mepilex dressing, pillows for off loading." The left buttock assessment is "pressure Ulcer, no change".

01/12/14 at 1000, left buttock is listed as "Pressure ulcer. No change".


Patient #5

A) Patient #5 was admitted on 01/05/14 and was inpatient at the time of the survey. Clinical record review revealed a Stage I pressure ulcer at the coccyx from admission through 01/14/14 at 2200.

On 01/15/14 at 0953 documentation of the Wound /Incision Assessment, "Coccyx: No pressure ulcer noted. Coccyx is reddened but blanchable. Pt. will continue with turn Q (every) 2 with barrier cream applied as she is having diarrhea."

On 01/15/14 at 2200 The Wound /Incision Assessment revealed "Coccyx: Pressure Ulcer Stage II, Partial thickness."

On 01/16/14 at 1000 and 2200 "Dressing Change per Physician Order".

On 01/17/14 at 1000 "dressing change per physician order".

On 01/17/14 at 2200, dressing change per physician order, coccyx. Pressure ulcer, clean dry intact with Mepilex dressing. Stage one is documented through 01/23/14 at 0926.

On 01/23/14 at 2200 the wound incision Assessment lists the coccyx wound as an "abrasion." No measurement of the Pressure ulcer at the coccyx was documented in the clinical record. The findings were confirmed by RN at the time of clinical record review 01/24/14 at 1115.

Based on observations, interviews and records review, it was determined the facility failed to implement the plan of care and reassess the patient's nursing care needs and response to nursing interventions for Patient # 7. The failed practice resulted in actual harm to Patient #7 and had the likelihood to affect all patients.


A. Observation on 01/24/14 at 1220 with RN #2 and Director #2 revealed Patient #7 with two open areas along her spine, mid and lower back. RN #2 denied Patient #7 had additional breakdown. Surveyor requested to visualize Patient #7 ' s heels, RN #2 picked up the left heel and stated " it's just bruised ." Surveyor informed RN #2 that the area on the heel had a blister. When asked how it would be described, RN #2 stated it was a "Stage I" then stated " It ' s probably a stage II, and stated it was " one-half dollar size blister " and that the heel was "soft." RN #2 confirmed at the time of observation that she was not aware of the blister prior to observation with the Surveyor.

At the time of observation on 01/24/14 at 1220, Patient #7 was supine in bed with both heels positioned flat on the mattress. Heels were not bridged off the mattress to prevent pressure. In an interview with RN #2, she stated "we ordered the Kin Air bed on Saturday and we got it on Monday."


B. Clinical Record review of the plan of care on 01/24/14 with Director #2 revealed the problem "Impaired Skin Integrity" created 01/17/14 at 0859. The outcome is listed as "Skin Integrity Intact". The interventions listed were "Implement Skin Protection Measures, Use Pressure dispersing mattress, pressure relieving techniques, avoid shearing, bridge heels off bed, educate bed mobility and skin care."


C. The facility failed to follow the plan of care in that the patient's heels were not bridged at the time of observation and harm was noted in that Patient #7 was discovered with a pressure ulcer at the time of observation by the Surveyor.