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Based on medical record review, staff interview and policy and procedure review, the facility failed to ensure that the nurse assessed the condition of Patient #1's pressure ulcers and the need for pain medication prior to provision of pressure ulcer treatment and were assessed. One (1) of one (1) patient was affected (Patient #1).

Findings include:

The facility ' s Pain Management, Pain Assessment/Reassessment Policy Number PC 010 contained the following requirements:

"II. A. Assessment/Reassessment of Pain:
1. Patient will be assessed for pain upon admission to the hospital. Thereafter, the patient is monitored for pain: a. At least every shift. b. Within one hour of an intervention or treatment to relieve pain. c. Outpatient ' s assessments are done as appropriate to setting, condition, and procedure. 2. Ask the patient how he/she feels. Include the family or significant others in the assessment if appropriate. 3. Have the patient describe their pain in terms of location, intensity, duration and how their pain has affected activities of daily living.

The facility ' s Wound Assessment Policy/Procedure page one (1) contained the following requirements:
"Procedure:
1. Within the 1st 4 hours of admission all patients should be assessed for wounds.
2. All wounds should be identified by location and description.
3. Wound(s) should be measured by size, width, depth, and length.
4.A description of the wound bed, drainage (if applicable), odor of drainage, and temperature of the surrounding tissue (ex. Red and warm to touch) should also be documented.
5. Wound(s) should be reassessed with each dressing change as ordered by physician."

Observation of pressure ulcer treatment for Patient #1 on 3/16/11 from 10:55 a.m. to 1:20 p.m. revealed during the treatment the patient cried out "oh, oh". When asked if it hurt when the dressings were changed, the patient stated, "Indeed it does." Interview with the treatment nurse on 3/16/11 revealed the patient had not been given pain medication since 12:00 p.m. on 3/15/11.

Review of the medical record revealed the following: Medication ordered included Tylenol 325 milligrams (mg) two (2) tablets orally every four (4) hours PRN (as needed), Percocet 10/325 mg tablets orally every six (6) hours PRN. The patient was admitted to the facility on 03/07/11 with five (5) pressure ulcers. There was no documented evidence that the stage and size of the pressure ulcers were assessed until 3/17/11. Review of the photographic wound documentation on 3/07/11 revealed the following information: the wound size, width, depth, and length were not assessed for pressure ulcers on the patient ' s right ankle, left ankle, right buttock, inner buttock, and left lower buttock. There was no documented evidence that that stage of the pressure ulcer was assessed on the: right ankle, left ankle, right buttock and left lower buttock.
Wound assessments on 3/17/11 revealed the following information. The pressure ulcer on the right ankle was a stage III. It was 3.5 centimeters (cm) long, 3 cm wide, and 0 cm deep. The one on the right buttock was a stage IV. It was 3 cm long, 2 cm wide, and 0 cm deep. The one on the sacrum was a stage III. It was 2 cm long, 1.5 cm wide, and 0.5 cm deep. The one on the left buttock was 1 cm long, 1 cm wide, and 1 cm deep. The one on the left heel was 4.6 cm, 8 cm wide and 0 cm deep.

These findings were discussed and confirmed during the exit interview on 03/17/11 from 3:00 p.m. to 3:30 p.m.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that all entries in the medical record are timed for a sample of 24 medical records including active and discharge records and for 17 surgery records.

Findings include:

Sixteen (16) inpatient medical records were reviewed along with eight (8) discharge records from 05-12-11 for a total of 24 medical records.

On 9 of 24 medical records reviewed, all progress notes had not been timed when entered in the medical record.

On 13 of 24 medical records reviewed, all physician orders had not been timed when entered into the medical record. This included orders written by the physician as well as when routine order sheets were placed into the record.

On six (6) of 17 surgery records the pre-anesthesia evaluation had not been timed. Refer to A1003

Based on review of Medical Staff Rules and Regulations and review of medical records the hospital failed to ensure that records of discharged patients are completed within 30 days of discharge.

Findings include:

1. The Medical Staff Rules and Regulations consider a medical record delinquent when it has not been completed for any reason within 30 calendar days following a patient's discharge.

2. The physicians' incomplete medical record list was generated at 12:23 p.m. on 05-13-11. According to this list the hospital has total of 1400 records that are delinquent over 30 days, which represents a delinquency rate of 40 percent. Of this number 145 records belong to seven (7) physicians that have been suspended from Medical Staff until their records have been completed.

3. It was noted that the medical records in the physicians' incomplete files still dated back to 2010.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that all pre-anesthesia evaluations were timed as to when the evaluation was performed.

Findings include:

On six (6) of 17 surgery records reviewed, the pre-anesthesia evaluation had not been timed when it was performed.