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Based on record review and interview the facility failed to develop and implement a plan of care for 1 of 5 (#2) patients who developed a pressure ulcer.

Findings:

Review of the medical record for sample patient #2 revealed the patient developed a pressure ulcer during hospitalization. Patient #2 had an admission date of 10/10/10 for complaint of lower back pain. Further review of patient #2 ' s record revealed an admission nursing assessment with a Braden score of 18; the patient was not recognized to be at risk for skin breakdown. On 10/15/10, after identification and assessment of the pressure ulcer, the facility did not follow-up with care plan update regarding the ulcer and there is no documentation in the medical record that the physician was notified of the ulcer.

Interview of both the corporate and facility nursing administrators on 11/4/10 at 2:30 PM confirmed the absence of physician notification and care plan implementation of care for the pressure ulcer in the medical record. No other documentation was presented by the nursing team to substantiate physician notification regarding the presence of the pressure ulcer.