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Based on interviews, review of medical records and other documents it was determined that nursing services failed to ensure (1) that each patient determined to be a high risk for the development of pressure ulcer has preventive measures implemented promptly; and (2) that monitoring of pressure ulcers is implemented in accordance with the facility's policy and procedure. These findings were noted in 4 of 12 patients' records reviewed (patient #1, 2, 3 and 4).

Findings include:

Patient #1 is a 66-year-old patient with multiple medical conditions including multiple previous strokes with cumulative residual of generalized muscle weakness, poor verbal output, slurred speech, and dysphagia (difficulty in swallowing). The patient is noted to be bed and wheelchair bound.

The patient presented to the Emergency Department (ED) on 1/18/14 and triaged at 1:41 PM with a chief complaint of altered mental status. The initial nursing assessment conducted in the ED at 2:00 PM was not comprehensive; it lacked documentation of the patient's neurological and mobility status as indicated in the "Nursing ED Assessment Form". The assessment indicated the patient is nonverbal, has slurred speech, uses an assistive device, and has intact skin, but failed to include the patient's care needs related to her impaired mobility.

The Facility's policy titled "Pressure Ulcer Prevention and Treatment", last revised 8/14, notes that all patients including patients in the Emergency Department for 12 hours or more are to be assessed utilizing the Braden Scale for predicting Pressure ulcer risk. The policy further notes that Braden risk score of 18 or less is utilized as a basis for implementing interventions for pressure ulcer prevention. (The Braden Scale: very high risk - total score of 9 or less; high risk - total score of 10 to 12; moderate risk - total score of 13 to 14; mild risk - total score of 15 to 18; and no risk - total of 19 to 23.)

On 1/18/14 at 6:10 PM, nursing noted the patient is admitted with diagnoses of Urinary Tract Infection and generalized weakness, and was awaiting bed placement. The patient remained in the ED on a stretcher until she was received in the Neurological Unit at about 3:00 AM on 1/21/14. Except for a nurse's note on 1/19/14 at 12:05 PM that indicated the patient was turned and repositioned, pressure ulcer prevention measures were not in place during the patient's extended stay in the ED.

The initial nursing assessment on 1/21/14 in the neurological unit identifies the patient as a high risk for pressure ulcer development evidenced by a Braden Score of 14. Although the ED nursing assessment on 1/18/14 indicated the patient's skin was intact, the assessment of the patient upon arrival on the unit on 1/21/14 revealed a healed dry scab to the mid sacral area (skin area covering the triangular bone that extends from the base of the spine to the upper back part of the pelvic cavity, that is wedged between the two hip bones; the upper part which connects with the last lumbar vertebra - the last of five vertebrae between the rib cage and the pelvis - and the lower part which connects with the coccyx or tailbone), a deep tissue injury on the left ischium (skin area covering the lower and back part of the hip bone) 5 centimeters X 5 centimeters (5 cm x 5 cm), and a left heel unstagable ulcer.


- Patient #2 is a 63-year-old male with history of hypertension (HTN - elevated blood pressure in the arteries), osteoarthritis (mechanical abnormalities involving degradation of joints), and gout (elevated levels of uric acid in the blood; the uric acid crystallizes, and the crystals deposit in joints, tendons, and surrounding tissues; it is usually characterized by recurrent attacks of acute inflammatory arthritis - red, tender, hot, swollen joint or joints).

. The patient was evaluated in the Emergency Department on 8/1/14; he was status post fall at home with complaints of headaches and elevated blood pressure.

The ED nursing assessment conducted on 8/1/14 at 10:00 AM failed to identify patient's skin condition as prescribed in the "Nursing ED Assessment Form". The nurse noted the patient's skin was within normal limit and intact with no pressure ulcers. However, upon admission of the patient to the inpatient unit on the same day, the initial nursing assessment on the unit at 10:00 PM notes stage II pressure ulcers on the patients right ischium, right buttocks, and left buttocks.

- Similarly, the ED nursing assessment of Patient #3 conducted on 8/1/14 at 10:30 PM notes an intact skin and the absence of pressure ulcers. The assessment failed to identify a stage II Coccyx (tailbone) ulcer measuring 4 cm x 2 cm, that was identified on 8/2/14 at 11:00 AM upon assessment of the patient in the inpatient unit.

At interview with Staff #1 on 8/6/14 at 11:30 AM, she stated patients' skin assessment in the ED was not accurately documented and prevention measures were not documented for patients who are at risk for developing pressure ulcers.

Review of MR #4 revealed this patient, an 88 year old, was admitted on 5/6/14 with 2 vessel CAD (coronary heart disease caused by plaque building up along the inner walls of the arteries of the heart, which narrows the arteries and reduces blood flow to the heart) for CABG (coronary artery bypass graft, also known as coronary artery bypass surgery). The patient's past medical history is significant for HTN, BPH (benign prostatic hyperplasia, also called benign enlargement of the prostate) and mitral valve regurgitation (disorder of the heart in which the mitral valve does not close properly when the heart pumps out blood). The skin was noted to be intact on admission. A stage II pressure ulcer to the sacrum was identified on 6/4/14 measuring 7 cm x 4 cm. On 7/23/14 two (2) stage III pressure ulcers were noted to the left and right buttock without description as to size, color, discharge or odor. This was brought to the attention of Staff #2.





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