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Based on observation, record review and interview, the facility failed to meet the Condition of Participation (COP) for Governing Body as evidenced by the failure to provide nursing services to meet patient needs (refer to A-385, and A-396).

Based on observation, record review and interview, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by the failure to develop care plan, assess and reassess, and follow treatment orders for patients 4 (SP#9, SP#10, SP#32, and SP#33) of 7 Sampled Patients requiring wound care; and failure to provide adequate supervision and evaluation of the clinical activities of non-employee licensed nurses providing dialysis.
Refer to A-396, and A-398

Based on record review and interview, the facility failed to ensure that wound care management include a care plan, assessment and reassessment of wound condition, following physician's order for treatment, and documentation of measures provided and administered as evidenced in 4 (SP#9, SP#10, SP#32, and SP#33) of 7 Sampled Patients (SP).

The findings include:

1. Clinical record review of SP#9 conducted on 04-04-11 thru 04-08-2011 revealed a 76 year old female patient who was admitted on 03-25-2011 with a diagnosis of infected right heel ulcer. SP#9's medical history also included dementia and degenerative joint disease. The wound care orders from 03-25-11 was specific to clean the right heel ulcer with Normal Saline (NS), apply Santyl ointment, cover with dressings and repeat once a day.
On 03-26, the Photographic Wound Documentation form showed a Stage III right heel ulcer measuring 4.2 centimeter (cm) times (x) 3.5cm x 0.3cm (length x width x depth) and a Stage II sacral ulcer with measurements of 3.5cm x 7cm x 0.2cm (length x width x depth). On 03-26-11, the right heel ulcer was treated with Normal Saline and Santyl and the sacral ulcer was treated with NS and Granulex.
On 03-27-11, there was no documentation about provision of wound care to the right heel as ordered to be done daily by the physician.
On 03-28-11, it was documented in the nurse's notes on the Skin Assessment Form that wound care was done and a picture was taken at the Wound Care Center and placed in the patient's chart. Record review revealed no picture in the chart as noted on the nurse ' s notes.
New wound care orders for the sacral ulcer were written on 03-29-11 and on 03-30-11, SP#9 underwent an Excisional debridement of the right heel ulcer with application of a cellular graft, excisional debridement to the level of the bone. Wound care of the right heel was being done by the Podiatry Resident as documented.
On 04-06-11, the Skin Assessment Form documentation showed a new Stage II wound ulcer on the T-spine area measuring 2.1cm x 2.5cm x 0.1cm (length x width x depth) and a new Stage I pressure ulcer on the right hip area. These pressure ulcer areas were treated with Santyl and Dermacall.

Further review of SP#9's clinical record revealed no current and ongoing nursing care plan that addresses maintaining skin integrity from the day of admission up to patient date of discharge. The wound care orders written on 03-29-11 showed no frequency on how often the wound care was to be done. No clarification of the orders was done. There was no indication that the Wound Care Medication Protocol form was to be followed for SP#9.

2. Clinical record review of SP#10 conducted on 04-04-11 thru 04-08-11 revealed an 89 year old female, a resident of an ALF (Assisted Living Facility) who was admitted on 02-02-2011 due to diarrhea and severe pain on the LLE (left lower extremity). Documentation in the Photographic Wound form on 02-03-11 showed a stage IV sacral ulcer with the following measurements: 2cm x 1.6cm x 1.5 cm (length x width x depth) and the initial treatment was the application of the Silver dressing. On 02-02-11, an order for wound care consult was written. An order on 02-03-11 requested Wound Care for evaluation of the right sacral ulcer. An air mattress was also requested on this date.

Record review showed no documentation that wound care was done from 02-04 thru 02-07-2011 on the sacral ulcer except the initial treatment on 02-03-11. Further review showed no current and ongoing nursing care plan could to address SP#10's breakdown of skin integrity. There was lack of follow-up regarding wound care of the sacral ulcer although the order was written at least three (3) times.

Review of the Hospital's Wound Care Protocol conducted on 04-06-11 revealed that the policy and procedure on Pressure Ulcer Prevention Plan was to have a photograph of the ulcer prior to discharged. Review of the clinical record showed no documentation of the wound status prior to discharge on 02/07/2011.

Further clinical record review of SP#10 conducted on 04-04 thru 04-08-2011 revealed that the patient was readmitted on 02-09-2011. The Emergency Physician Record showed documentation of a large Stage IV sacral ulcer which was bleeding. Admission orders on 02-09 included Wound care consult and to apply Santyl to the sacral wound site daily. The Photographic Wound Documentation form on 02-10-11 revealed a Stage III sacral ulcer measuring 7.0cm x 7.0cm x 0.5cm (length x width x depth). The right heel photograph taken on 02-10 showed an unstageable pressure ulcer on the right heel. The initial treatment for both of these sites was the application of Granulex.
On 02-11-11, new wound care orders were written without the frequency of the treatments to be done; a Nutritionist was ordered for evaluation for protein and vitamin supplement. On 02-11-11, an order was written for Wound Care to reevaluate sacral ulcer for debridement. On 02-16-11, the debridement of the sacral ulcer was done.
Daily wound care progress notes showed no assessment and reassessment of the wound's status, and evaluation of the wound's response to treatments. SP#10 was discharged to the ALF on 02-18-2011. Discharge record showed no evidence of the wound's status and assessment prior to discharge.

Interview with the 2nd Floor Medical Surgical Nurse Manager on 04-07-2011 at 12:15pm confirmed the findings.

3. Clinical record review conducted on 04-07-11 to 04-08-11 for SP#33 revealed that the patient was admitted to the facility on 11-04-10 with a diagnosis of chronic kidney disease, chronic ventilator dependent respiratory failure, hyponatremia, electrolyte imbalance, Hypertension, Diabetes Mellitus Type II, Sacral Decubitus Ulcer (stage IV) and AIDS (Auto Immune Disease Syndrome).
On 11-05-10, SP#33 wound care assessment was done but showed no appropriate plan of care. Further review of records showed that SP#33 had an order for wound care consult on 11-05-10 but was first seen by the wound care physician assistant (PA) on 11-09-10. The PA wrote on the progress note "start Silver dressing and Santyl on sacral pressure ulcer-stage IV" but there was no physician order written for this treatment.
On 11-12-10, the wound care doctor wrote an order for sacral ulcer Magnetic Resonance Imaging (MRI) to rule out osteomyelitis but no treatment order written. On 11-20-10, the first order for treatment on the sacral ulcer was written as "Discontinue silver dressing to sacral ulcer and continue with foam dressing change daily". On 11-30-10, the wound care doctor ordered "discontinue silver dressing to sacral ulcer, continue with santyl and calcium algenate cover with foam dressing and secure with Hypofix or equivalent". Review of the nurses' progress notes and medication administration record showed no documentation that the treatment orders for the patient's sacral pressure ulcer were done as ordered.
Further review of record showed that the patient's sacral pressure ulcer had been treated with zinc oxide 20 percent (%) ointment from 11-05-10 to 11-30-10 as ordered by the attending physician based on the patient's medication reconciliation on day of admission on 11-04-10. Review of the daily nurses' notes from 11-05-10 to 12-01-10 showed sacral pressure ulcer under wound care services or wound care done but no written specific treatment administered per physician order.

Interview with the second floor Medical/Surgical Nurse Manager conducted on 04-08-11 at 10:00am confirmed above findings that SP#33 did not receive proper wound care treatment as ordered. He also admitted that there was no appropriate plan of care written for the sacral ulcer Stage IV as a result of nursing assessment, and that the wound care consult should have been followed up within 24 hours after the order was received as per facility policy and procedure.

4. Clinical record review conducted on 04-07-11 of SP#32 revealed that the patient was admitted with diagnoses of Acute Cellulitis Right Foot, Bilateral Pleural Effusion, Diabetes Mellitus Type II, Renal failure/Renal Insufficiency, and Congestive Heart Failure. Review of the plan of care showed no documentation addressing the wound care on right foot and the patient being on dialysis.

Interview with the wound care nurse conducted on 04-07-11 at 12:55pm confirmed above findings that SP#32 did not have appropriate care plan addressing the wound on right foot and patient being on dialysis.