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Based on staff interview and medical record review, it was determined the facility failed to reassess a patient for changes in skin condition timely, and to revise the plan of care timely based on identified changes to meet the patient's needs. As a result the facility failed to identify and treat symptomatic indicators timely. This failure affected 2 of 3 sampled patients (#1 and #2).
The findings are:
Medical record review revealed patient # 1 was transferred from another local Acute Care Hospital, and admitted to HealthSouth Sunrise Rehabilitation Hospital on 04/28/2012. Review of the Initial Nursing Assessment, body figure, dated 04/28/2012 revealed patient # 1 was admitted with redness noted on right buttocks and the bottom of both feet.
Review of the Interdisciplinary Progress Note dated 04/28/2012 1700 (5:00 PM) revealed the admitting nurse documented, "buttocks reddened, crack with open area. Calmoseptine applied. Bilateral arms and left leg with reddened areas. Bilateral heels reddened."

Review of the Physician ' s Admission Telephone orders dated 04/28/2013 1800 (6:00 PM), revealed: Calmoseptine to buttocks twice daily and PRN (as needed) for redness. Skin care treatment per Hospital protocol. Order read and verified with Physician.

In an interview with the Nurse Manager and the Risk Manager on 08/20/2013 at 1:10 PM, the Nurse Manager stated, " the Protocol is typically for sacrum; we apply Calmoseptine. Review of the Skin Care Treatment Hospital Protocol provided by the Nurse Manager revealed the protocol does not address or call for the application of Calmoseptine.

In an interview with the Wound Care Nurse on 08/20/2013 at 1:25 PM, she stated, " a physician ' s order is required for Calmoseptine. The protocol is all preventive measures and includes turn and repositions, cushions, surfaces, prevent friction, protective films, protection of bony prominences and moisture management, family education. "

Review of the Interdisciplinary Daily Documentation (IDD) Daily Nursing Assessment revealed two places on the Form where the nurse can document the skin assessment
Review of the (IDD) Daily Nursing Assessments for the patient ' s entire hospitalization revealed:
On 04/29/2012 the Integument section (bolded print) for Skin Breakdown has not documentation and is left blank. A second page of the IDD document contains a written assessment documenting, "buttock reddened opening with crack of Coccyx area Calmoseptine applied." This condition / information would be new as it is not documented in the Initial Nursing Assessment.

On 05/02/2012 Skin Breakdown documents "redness to buttocks. Calmoseptine applied as needed." The Assessment does not include documentation of skin integument.
On 05/03/2012 and 05/04/2012 Skin Breakdown notes documents: "none". The assessment note does not include documentation regarding skin integument.
On 05/05/2012 Skin Breakdown is documented as none, however under description the following is documented: "redness and excoriated area on buttocks." The Assessment note does not include documentation regarding skin integument.
On 05/06/2012 Skin Breakdown is documented as: redness to buttocks. Calmoseptine applied at diaper change. The Assessment note does not include documentation of skin integument.
The review of the medical record disclosed on 04/30/2012, 05/01/2012, 05/07/2012, 05/08/2012, 05/09/2012, 05/12/2012 and 05/13/2012, there is no documentation , found or provided regarding the patient's Skin Breakdown status. Furthermore on the dates nursing notes are written as presented above the patient's skin integument status is not addressed or acknowledged.

On 05/10/2012 assessment of the patient's Skin Breakdown status is not documented. The assessment note documents: Sacral wound; Dermagran and Allevyn applied. Clinical characterstics of the sacral wound is not written
On 05/11/2012 Skin Breakdown status is not documented. The assessment note documents redness to sacral area noted. Patient to be referred to Wound Care Nurse for further eval.
As of 05/11/2012 the clinical / nursing documentation regarding the patient's skin condition and Coccyx wound status is inconsistent, some notes acknowledge the presence of a Coccyx wound, some do not. There is never any written clinical note, in accordance with nursing standard of practice describing the pressure sores clinical characteristics as is required.
Furthermore the physician's notes for 05/05/12, 05/06/12, 05/12/12 and 06/01/12 differs with the nurses notes. The progress notes written by the physician on 05/05/12, 05/06/12, 05/12/12 and 06/01/12 documents, "Skin: Dry, no sacral or heel ulcers noted."
As of 5/11/12 the nurse's notes call for wound care consult for the sore at the patient's Coccyx.
Review of the wound care nurse ' s note dated 05/12/2012 0945 (9:45 AM), revealed documentation of the wound as right buttock and coccyx 5.5 cm X 4.5 cm unstageable with necrotic tissue, small amount of slough, small area of granulating tissue.
The above note is not congruent with the physician's note of 5/11/12 declaring, "no sacral or heel ulcers noted."
The patient's medical record contains Physician Wound Care Orders dated 05/12/2012, which specifies wound care location right buttocks. The orders are to clean the right buttocks with Normal Saline then apply Santyl and Opsite, cover with Allevyn daily. Stage IV 3000 Alternating mattress and Roho cushion. The nurse signed the orders 05/12/2012 0945 (9:45 AM).
On 05/14/2012 Skin Breakdown documents: buttocks dressing dry and intact; instruct patient to reposition self; the assessment note documents patient education to reposition self to prevent skin breakdown. On 05/15/2012 Skin Breakdown is documented as: buttocks dressing dry and intact. The assessment note documents at 8:00 AM, "dressing to right buttocks changed cleaned with Normal Saline. Santyl and Opsite applied and Allevyn on top. Scant serosanguinous drainage with necrotic tissue noted. Patient has air mattress on bed."
The above notes are supportive evidence of a distinct change in the patients skin condition between 5/11/12 and 5/14/12. At the time of record review, the medical record of patient #1 did not contain any evidence of the interdisciplinary team (IDT) reassessing the established plan of care between 5/11/12 and 5/14/12 for its failure to manage risk factors for pressure ulcers identified at the time of admission and the Initial Assessment.
To further substantiate a change in the patient's condition identified as of 5/11/12 and subsequently, is found dated 05/15/2012 when the Dietitian recommended Rejuven and Prostat and to increase Ensure. The Attending Physician signed the order, ordered air mattress, referral to wound care nurse and discuss with me. He also ordered Pre-Albumin level with the next lab. He ordered re-consult with Urologist regarding Foley secondary to wound and bladder incontinence a Roho cushion to wheelchair.

On 05/16/2012 Skin Breakdown is documented, buttocks dressing dry and intact; the nursing assessment note documents at 9:10 AM, dressing to sacral area changed as ordered. wound bed with black eschar. Scant serosanguinous drainage noted, and at 2:30 PM dressing to sacral area changed. Santyl ointment applied as ordered.

Review of Physician Orders dated 05/16/2012 reveal orders right buttock and coccyx 5.5 cm (centimeters) x 4.5 cm unstageable with necrotic tissue small amount of slough and granulation tissue. Turn and reposition patient every two hours while in bed. Continue daily wound care to buttock and coccyx Review of the medical record revealed the wound care nurse ' s note dated 05/16/2012 0910 (9:10 AM), documents dressing to right buttock cleaned with Normal Saline, Opsite and Allevyn applied as ordered. Necrotic tissue in wound. Scant sanguineous drainage noted.
It is not until 5 days after a recognized change is documented in the patient's medical record (on 05/11/12) that the Interdisciplinary Progress Note dated 05/16/2012 1545 (3:45 PM) acknowledges and document: Wound care note right buttock and coccyx 5.5 cm x 4.5 cm unstageable with necrotic tissue small amount of slough small area of granulating tissue recommend continue clean with Normal saline cover with Opsite the Allevyn daily turn and reposition patient every two hours and as needed. Patient is using air mattress when in bed and Roho cushion when in wheelchair will continue to follow up.
Review of the Pulmonary Consultant note dated 05/16/2012 reveals the Physical Exam documented Integument: The patient does have severe decubitus ulcer, which is being dressed by wound care.
On 05/17/2012 Skin Breakdown is documented as sacrum open wound and dressing. The nursing assessment note documents, buttock wound with dressing.
Even though the patient has co-morbidites contributing to an unavoidable decline, there was a distinct change in the status of the patient's skin condition between admission 4/28/12 and 5/11/12. There was no supportive evidence found during this timeframe indicating the risk factors for pressure ulcers, as identified on admission were being managed effectively and tiemly.
In an interview with the Attending Physician for patient #1 on 08/20/2013 at 3:47 PM, he was asked his opinion about whether the pressure ulcer was preventable or unpreventable. He looked at the three photographs of the pressure ulcer taken from admission to discharge and stated, " it ' s one of those because it was a black area. I don ' t really know what ' s underneath."

At the time of admission there was no necrosis (black area); while hospitalized there was a change in the patient's skin condition. The assessments ongoing as of admission 04/28/12 through 05/11/12 lacks descriptive and consistent evidence of the patient's skin condition in accordance with practice standards (refer to evidentiary findings above in this report). The assessments during the stated timeframe fail to describe the characteristics of the patient's skin and pressure sore status, neither is there evidence of an assesment of the effectiveness of the interventions or approach to care being rendered during the stated timeframe. The patient's skin status / pressure sore changed from redened to necrotic while care was being delivered without accurate and appropriate assessments.

2. Review of the medical record for patient #2 revealed the patient was admitted to HealthSouth Sunrise Rehabilitation Hospital on 07/30/2013.
Review of the Nursing Admission Assessment dated/timed 07/30/2013 1700 (5:00 PM) revealed patient # 2 had an open red area to her sacrum, a hematoma to her forehead and hematoma to her left groin, left hand was swollen and left side of neck were bruised at the time of admission. Air mattress overlay was ordered 07/30/2013 with orders for skin care treatment per protocol.
Review of patient #2 ' s medical record revealed it does not contain a Plan Of Care developed and established by the interdisciplinary team to manage the identified skin integument problems based on the assessment and the treatment orders to meet the patient's needs. A care plan for the patient's identified skin breakdown, "open red area to sacrum" was not found nor provided.
On 08/07/2013, 8 days after admission, there is documentation of a stage III wound to the patient's Coccyx and a care plan.
There is no documentation of the wound to the coccyx in the Physician ' s follow up notes until 08/15/2013.
Review of wound care orders dated 08/13/2013 reveal Sacrum Stage III clean with normal saline, apply Dermagran, cover with Optifoam Sacrum Monday, Wednesday, Friday. Turn side to side every two hours when in bed. Size Wise mattress, Roho cushion and pressure mapping.
Review of the wound care nurse note dated 08/13/2013 revealed Patient # 2 has a stage III on coccyx, Base is 20% slough, 80 % granulation edges attached, no odor, slightly tender to touch, peri wound is reddened. Patient stated she had an opened area for months without healing. Wound was cleansed with Normal Saline, Dermagran, applied and covered with Optifoam. Patient tolerated treatment without discomfort. Pressure redistributing mattress was ordered.
The interdisciplinary team failed to develop and establish a plan of care based on the patient's identified needs, to manage known and potential risk factors for pressure ulcers.
In further interview with the Nurse Manager on 08/20/13 at 1:30 PM it was revealed, " on 08/01/2013 the nurse asked for a wound care eval. It was supposed to go in the wound care book for the wound care nurse to see. It was filed in the chart instead, thus the wound was not written on the care plan. "
Review of the nursing notes dated 08/16/2013 reveals Patient # 2 ' s wound has yellow brown drainage. The Infection Control Officer was informed by the Nurse Manager on 08/20/13 that this note (08/16/2013) was discovered while reviewing the notes with Surveyor. As of the survey date there is no evidence of interdisciplinary team assessments with the development of appropriate interventions for care to be delivered based on accurate team assessments of the patient's needs.