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Based on record review, staff interview, and review of hospital policies, it was determined the CAH failed to adequately train, orient, supervise, and provide policies for nursing staff in relation to assessment, prevention and management of skin breakdown and other potential problems in patients. This directly impacted 4 of 6 patients (#1,#2,#3 and #6) whose records were reviewed. This failure impaired the ability of the CAH to meet the skin care needs and other pertinent patients' needs due to incomplete nursing assessments and missing or inadequate care planning. Findings include:

1. Patient #1 was a 91 year old male admitted on 1/18/10. He was a current patient at the time of the survey. The "Initial Patient Data Collection and Assessment" form, dated 1/18/10 at 8:10 PM, documented a Braden score of "9." According to the form, a score of "9" was considered to be a "very high risk" (of development of pressure ulcers). The form listed a number of recommended interventions for individuals considered at high risk. They included but were not limited to the following:
a.) Manage Moisture (use commercial moisture barrier; use absorbent pads or diapers that wick and hold moisture; address cause if possible; offer bedpan/urinal and glass of water in conjunction with turning schedule);
b.) Manage Nutrition (Increase protein intake; increase calorie intake to spare proteins; Supplement with multi-vitamin; act quickly to alleviate deficits; consults dietician);
c.) Manage Friction and Shear (elevate head of bed no more than 30 degrees; use trapeze when indicated; use lift sheet to move patient; protect elbows and heels if exposed to friction);
d.) Other General Care Reminders (No massage of reddened bony prominences; No donut type devices; maintain good hydration; avoid drying skin).

In addition to documentation of the Braden score, the "Initial Patient Data Collection and Assessment" form, documented Patient #1 had redness in the groin and penis tip and a small sore outside of Patient #1's heel that had scabbed and was healing.

Although the initial assessment indicated the patient was at high risk for skin breakdown, skin issues were inadequately addressed on Patient #1's care plan, dated 1/23/10. The only "problem" listed relating to skin breakdown was "Injury, High Risk Related to possible skin breakdown due to diarrhea. The interventions included "KCI overlay with frequent positioning. The additional skin interventions recommended on Patient #1's "Initial Patient Data Collection and Assessment" form were not carried forward onto the patient's nursing care plan. Therefore, the ongoing assessment and care planning were incomplete.

Also, there was inconsistent and incomplete follow-up of skin care assessments. For example, the following nursing notes failed to provide Braden scores and failed to document nursing assessment of the skin conditions previously described as red or scabbed: 1/22/10 at 7:15 PM, 1/23/10 at 6:45 AM and 7:10 PM, and 1/25/10 at 2:50 PM. During an interview on 1/25/10 at 4:00 PM, the RN Supervisor reviewed the record and confirmed documentation of skin assessments were incomplete. During an interview on 1/26/10 at 4:00 PM, the Chief Process Officer and Nursing Supervisor were interviewed together. They stated they expected the nurses to perform a head to toe assessment each shift as part of a basic standard of professional care.


2. Patient #3 was an 85 year old male admitted to the hospital on 5/03/09. The "Initial Patient Data Collection and Assessment" form, dated 5/03/09 at 3:25 PM, documented Patient #3 had a dark area on the coccyx. The Braden score, which measured level of risk for skin breakdown, was left blank. Without assessment and documentation of the Braden score at initial assessment, there would be no baseline from which to compare changes in skin condition. A nursing note, dated 5/03/09 at 7:25 PM indicated the patient was having diarrhea, his rectum and coccyx were reddened, and he had a Stage 1 decubitus on his left buttocks. Subsequent nursing notes documented a progression of skin breakdown. A nursing note, date 5/05/09 at 6:40 AM documented slight redness to the buttock region with a small blister. The nursing note, dated 5/05/09 at 6:00 PM, documented a Stage II decubitus on the coccyx with 4 blisters and a 4 inch diameter reddened area.

There was no documentation that nursing staff evaluated any of the described areas of concern on the nursing shift assessment notes that follow: 5/04/09 07:00 AM, 5/06/09 at 7:00 AM, 5/07/09 at 7:10 PM, 5/08/09 at 6:40 AM and 7:00 PM, or 5/09/09 at 7:00 PM. There were no Braden assessments present in any of the nursing documentation. During an interview on 1/26/10 at 4:00 PM, the Chief Process Officer and Nursing Supervisor were interviewed together. They stated they expected the nurses to perform a head to toe assessment each shift as part of a basic standard of professional care.


During an interview on 1/25/10 at 4:00 PM, the Nursing Supervisor reviewed Patient #3's medical record and confirmed documentation relating to skin assessment information was incomplete. She also confirmed the nursing care plans (dated 5/03/09 through 5/08/09) failed to identify skin issues as a problem.

3. Patient #6 was a 100 year old female admitted to the hospital on 12/28/09 with admitting diagnosis of heart failure. The "Initial Patient Data Collection and Assessment" form, dated 12/28/09 at 4:45 PM, was left blank under the sections marked cardiac, respiratory, gastrointestinal, and genitourinary. The skin assessment section noted the patient's skin was dry with poor turgor. No Braden skin assessment was done and the Braden score was left blank. Patient #6's initial care plan, dated 12/28/09, was developed based on the above assessment. No entries were made under the problem list on the patient's care plan, dated 12/28/09, pertaining to care and maintenance of the patient's skin. No interventions were mentioned on the patient's care plan for skin care or protection. On 1/26/10 at 3:30 PM the Chief Process Officer reviewed the patient's record and confirmed the comprehensive assessment was incomplete.

4. Patient #2 was a 74 year old male, admitted to the hospital on 1/21/10. Admitting diagnosis was possible pulmonary embolism. The "Initial Patient Data Collection and Assessment" form, dated 1/21/10 at 5:00 PM, documented the patient as being on anticoagulation medication since open heart surgery six months prior. The DVT Risk Assessment section was left blank. The Braden Score Assessment section was left blank. This assessment was used to develop Patient #2's initial care plan, dated 1/22/10. Patient #2's care plan did not include potential problems or nursing interventions related to skin care or blood clotting issues. On 1/26/10 at 3:30 PM the Chief Process Officer reviewed the patient's record and confirmed the comprehensive assessment was incomplete.

5. The CAH failed to provide specific training to nursing staff on what they were expected to complete and document in relation to comprehensive assessments on the "Initial Patient Data Collection and Assessment," form, dated 3/02/09, and the "Patient Data Shift Assessment" form, dated 3/02/09, which were primary assessment tools for nurses. According to the Chief Nursing Officer and the Nursing Supervisor during an interview on 1/26/10 at 8:45 AM, new nurse hires received 4-12 weeks of orientation; all nurses had mandatory yearly training. They confirmed there was no specific training on the completion of the "Initial Patient Data Collection and Assessment," revised 3/02/09, or the "Patient Data Shift Assessment." During the same interview, the Nursing Supervisor stated she assumed nurses understood they should thoroughly complete the forms initially and at each shift.

6. The hospital failed to have a policy to guide nursing staff on expectations for skin assessment and prevention and management of skin breakdown. Failure to have a written policy may have contributed to the failure of nurses to consistently complete skin assessments and initiate appropriate care planning. During an interview on 1/26/10 at 8:45 AM, the Chief Process Officer confirmed the hospital did not have a policy.

7. The primary forms, previously referenced, "Initial Patient Data Collection and Assessment," and "Patient Data Shift Assessment" had areas on the forms to write patients' Braden scores, which represented patient risk for developing pressure ulcers. Neither form had a guide on how to calculate a Braden score to determine the level of risk. The CAH failed to have a readily accessible Braden scoring tool for nursing staff to reference while paper charting skin assessments on patients. Failure to have a readily accessible tool available to nursing staff may have contributed to the failure of nurses to document Braden scores on patients.

Five RNs were interviewed on 1/25/10 and 1/26/10. All nurses confirmed the forms did not include guidance on how to calculate the Braden scores. When individually asked how they knew how to calculate the Braden scores, they provided a variety of responses. One RN stated that the scoring tool was available in the computer. Another RN said that if the patient came through the ED, then the scoring tool was on the ED documents and she referenced the ED's tool. Another nurse said she was not sure how to score a Braden but she took pictures of skin breakdown to document her findings. Another RN stated there was not a way to score it because the scoring tool wasn't provided.

The CAH failed to have a double check system in place to evaluate nursing staffs' understanding of and compliance with addressing patients' skin care issues.

Based on record review, staff interview, and review of hospital policies, it was determined the CAH failed to ensure nursing staff developed or kept current nursing care plans that reflected the initial or changing needs of patients in 3 of 6 patients (#1,#3 and #5) whose records were reviewed. This resulted in a failure to have a coordinated plan with interventions addressing individual patient problems. Findings include:

A hospital policy, "Nursing Care Plans (Critical Access)," revised 2/02/10, referred to the Care Plans as "problem lists." It stated that identified problems would have corresponding nursing care treatments with short and long term goals.

During an interview on 1/25/10 at 1:45 PM, the Chief Process Officer described two forms nursing staff used to document assessments. She explained that one form, titled "Initial Patient Data Collection and Assessment," revised 3/02/09, was completed by nursing staff at the time of patient admission. A second form "Patient Data Shift Assessment," dated 3/02/09, was completed each shift.

In addition to the forms completed by nursing staff, the Chief Nursing Officer, during an interview on 1/25/10 at 1:15 PM, explained that problems lists (care plans) were developed and updated at least in part as a result of interdisciplinary communication daily during "stand up" meetings. She explained that representatives from nursing, physical therapy, pharmacy, social services, utilization review, dietary and nutrition services, medical staff, and administration met 5 days per week to discuss patients and their needs. She further explained that a social worker took notes during the meetings and added to each patients' care plan based on the problems identified and discussed. She stated other disciplines also had the option of going into the computer and adding to patient care plans.

On 1/26/10 at 4:00 PM, the Chief Process Officer and Nursing Supervisor were interviewed together and jointly contributed to the following information. They stated that when physical therapy shared their findings and plans during the "stand up" meeting, the social worker would add the information to the "Problem List" for use by nurses. They stated that other disciplines, such as nurses and nursing aides could add to the Problem List documented by Social Work. They also stated the "Lead" RN would be responsible to make sure the care plans were complete. They stated they expected the nurses to perform a head to toe assessment each shift as part of a basic standard of professional care

The "Initial Patient Data Collection and Assessment" form listed Braden Skin Assessment Scores (used to determine level of risk for skin breakdown) and corresponding nursing actions related to various levels of risk (at risk; moderate risk; high risk; very high risk). The form listed a number of recommended nursing interventions for individuals considered at high risk. They included, but were not limited to: 1) implementation of turning schedules; 2) maximal remobilization; 3) protecting heels; 4) use of foam wedges for 30 degree lateral positioning; 5) use of pressure-relieving surfaces; 6) measures to manage moisture, nutrition and friction and shear. In addition, the form offered the nurse additional general care reminders, such as: avoid massaging reddened bony prominences, avoid donut type devices, maintain good hydration and avoid drying skin.

The following information contains examples of patients whose nursing care plans failed to reflect the initial or changing needs of the patients.

1. Patient #3 was an 85 year old male admitted to the hospital on 5/03/09. The "Initial Patient Data Collection and Assessment" form, dated 5/03/09 at 3:25 PM, documented Patient #3 had a dark area on the coccyx. The Braden score, which measured level of risk for skin breakdown, was left blank and therefore the assessment was incomplete. A nursing note, dated 5/03/09 at 7:25 PM indicated the patient was having diarrhea, his rectum and coccyx were reddened, and he had a Stage 1 decubitus on his left buttocks. Subsequent nursing notes documented a progression of skin breakdown. A nursing note, date 5/05/09 at 6:40 AM documented slight redness to the buttock region with a small blister. The nursing note, dated 5/05/09 at 6:00 PM, documented 4 blisters, a 4 inch diameter reddened area and a stage II wound located on the coccyx.

There was no documentation on the nursing assessment notes (5/04/09 07:00 AM, 5/06/09 at 7:00 AM, 5/07/09 at 7:10 PM, 5/08/09 at 6:40 AM and 7:00 PM, or 5/09/09 at 7:00 PM) that nursing staff evaluated any of the described areas of concern. There were no Braden assessment scores documented on any nursing notes during the course of hospitalization.

A physical therapy note, dated 5/06/09 at 2:44 PM, documented a skin evaluation in response to a physician's order. The note documented Patient #3 had an open wound with non-viable tissue and drainage and would require debridement, wound cleaning and dressing changes every other day. The information was not transferred to the interdisciplinary problem list or "care plan" dated 5/06/09 (or later) utilized by nursing staff. A physical therapist was interviewed on 1/26/10 at 3:30 PM. She stated that physical therapy shared their findings and plan at the "stand up" meeting but physical therapists did not routinely carry their plans over to the interdisciplinary problem list. She explained that physical therapists kept their own notes on goals and interventions.

A nutritional therapy note, dated 5/07/09 at 11:05 AM, documented Patient #3 was assessed to be at moderate nutritional risk related to skin breakdown, poor appetite, and a history of cancer and chemotherapy. The same note documented a nutritional care plan, including a fortified diet and encouraging nutritional intake and providing preferences as able. These nutritional recommendations were not included Patient #3's nursing care plan, dated 5/07/09 (and later) to ensure nursing staff reinforced and followed the dietician's recommended interventions.

During an interview on 1/25/10 at 4:00 PM, the Nursing Supervisor reviewed Patient #3's medical record and confirmed documentation relating to skin assessment information was incomplete. She also confirmed the care plan failed to identify skin issues as a problem.

2. Patient #1 was a 91 year old male admitted on 1/18/10 and was a current patient at the time of the survey. An "Initial Patient Data Collection and Assessment" form, dated 1/18/10 at 8:10 PM, documented Patient #1 had a Braden score of "9." According to the form a score of "9" was considered a "very high risk" for development of pressure ulcers. The initial assessment also specifically documented Patient #1 had redness in the groin and on the tip of his penis and a small, scabbed over sore on the outside of his heel. The "Initial Patient Data Collection and Assessment" form listed a number of recommended interventions for individuals considered at high risk.

Although the initial assessment indicated the patient was at high risk for skin breakdown, skin issues were inadequately addressed on Patient #1's care plan, dated 1/23/10. The only "problem" listed relating to skin breakdown was "Injury, High Risk Related to possible skin breakdown due to diarrhea. The interventions included "KCI overlay with frequent positioning. The additional skin interventions recommended on Patient #1's "Initial Patient Data Collection and Assessment" form were not carried forward onto the patient's nursing care plan. During an interview on 1/25/10 at 4:00 PM, the Nursing Supervisor reviewed the record and confirmed the skin care problem and recommended nursing interventions were not adequately incorporated into the nursing care plan/problem list and associated nursing interventions.



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3. Patient #5 was an 80 year old female admitted on 1/02/10 with a bowel obstruction. The patient's condition deteriorated and, according to the clinical record in the Patient Progress Notes, a PICC line was inserted, for the administration of IV fluids, sometime between 12:00 PM and 7:00 PM on 1/04/10. The actual time of the procedure was not documented. An NG tube was also placed at 2:10 PM on 1/04/10, for drainage of stomach contents. While these procedures were documented in the Patient Progress Notes, no additions or nursing interventions were created on the patient's care plan (problem list), dated 1/03/10, to address these changes in the patient's condition. The patient's care plan was not updated to reflect additional patient needs.

On 1/26/10 at 3:45 PM the Chief Process Officer reviewed the patient's record and confirmed the care plan did not reflect the patient's change in condition.

The CAH failed to ensure care plans were appropriately created and updated for all patients.