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Based on record review and interview, the hospital nursing staff failed to properly assess and evaluate 3 of ( 9, #10, #11) of 3 patients with pressure sores admitted after 24 hours. Findings include:

Interview with the 7 HC Nurse Manager, on 1/12/10 at approximately 12:00 p.m., revealed that patient #8 and #9 were current patients on the unit with pressure sores. According to the Nurse Manager, patient #8 was admitted from an extended care facility on 1/11/10 with pressure sores. Review of the nursing assessment with the Nurse Manager revealed no documentation of area, size or stage of pressure ulcer. It was determined that there was still a window of time (12 hours) for staff to assess and document the pressure ulcers.

Review of patient #9 ' s medical record with the 7 HC Nurse Manager, on 1/12/10 at approximately 12:30 p.m., revealed that the patient had a coccyx and buttock pressure ulcer, both stage 3 on 1/11/10. The Nurse Manager stated at that time that the patient was transferred from another facility with the pressure ulcers. Daily documentation of the pressure ulcers revealed that the staff did not measure the pressure sore areas. Further review of the hard copy and electronic medical record of all nursing assessments, with 7 HC Nurse #7 at approximately 3:30 p.m., revealed that the patient was admitted on 12/23/09 with no documentation of pressure ulcers upon admission. Further review of the records revealed that the pressure sore was first documented on 12/25/09 as coccyx and right buttock, stage 3, no size or measurements documented. Review of pressure ulcer assessments throughout the patient ' s current hospitalization revealed that there were no size or measurements documented. Additionally, the patient had no pressure ulcer assessment documented on 1/7/10.

Review of pressure sore data revealed that patient #10 was a current patient with pressure ulcers on 7 HC. Review of the patient #10 ' s hard copy and electronic record with Nurse #7, on 1/12/10 at approximately 4:00 p.m., revealed that the patient was admitted on 12/18 with documented pressure ulcers. The pressure ulcers were documented as coccyx stage 2, right iliac or buttock stage 2 and left iliac or buttock stage 2. No size or measurements were documented throughout the current hospitalization.

Interview with the Director of Corporate Safety and Manager Nursing Quality on 1/12/10 and 1/13/10 revealed that the hospital did not have a policy and procedure on measuring pressure sores. Interview with the Wound Care Physician, on 1/13/10 at approximately 8:30 a.m., revealed that measuring sores was the standard of care and that the field or prompt was in the electronic documentation. According to the Physician, the nurses were supposed to document the size of pressure ulcers. The Physician also stated that once he was called in for consult, he followed the patients. A review of the electronic record with the Director Corporate Safety on 1/13/10 revealed that fields/prompts for the size of the pressure ulcers were sometimes displayed and sometimes not.

Review of the hard copy and electronic record of patient #11 revealed that the patient was admitted on 10/28/09 without documentation of a pressure sore until 10/31/09. On that date, the pressure ulcer was documented as a stage 1, buttock, coccyx bilateral midline, red unblanchable, painful. From 10/31/09 to discharge on 11/5/09, the pressure ulcers continued to be staged 1 or 2. There was no size or measurement documented throughout the nursing assessments. Just prior to development, the patient ' s Braden Scores on 10/30/09 and 10/31/09 were 13 on both days. This meant that the patient was high risk for development of pressure sores and should have triggered implementation of " Pressure Ulcer Prevention: High Risk (Adult) Plan of Care " . Review of documentation with Director Corporate Safety on 1/13/10 at approximately 12:30 p.m. confirmed that measurements had not been documented, and a Braden Score of 13 was high risk and that the Pressure Ulcer Prevention Plan of Care had not been implemented.

It was noted on the " Braden Risk Assessment Scale " electronic screen documentation that: " If Braden total is 16 or less, a Positioning and Skin Care Task will display on the task list " and " If Braden total is 16 or less, implement the Pressure Ulcer Prevention: High Risk (Adult) Plan of Care " . The Medical/Surgical and Progressive Care (including 7 HC) policy and procedure (revised 10/19/09) documented that Braden scores would be done within 2 hours of admission, daily, changes in condition. Additionally, this policy and procedure on assessments and care planning revealed that skin would be assessed minimally daily at 0800 and 2000. The nursing staff had not done complete assessments (measurements) and had not followed up on their assessment when a Braden Score was 16 or less.

Based on record review and interview, the hospital nursing staff failed to update and implement a pressure ulcer prevention care plan for 1 (#11) of 2 patients requiring an updated plan. Findings include:

Patient #11 was admitted and had surgery on 10/28/09 for right above the knee amputation. The patient ' s initial Braden Scores were 20, 19, and 17. On 10/30/09 and 10/31/09, the patient had a Braden Scores of 13. On 10/31/09 it was documented that the patient developed a stage 1 buttock, coccyx bilateral, midline, red nonblanchable, painful pressure ulcer. The Braden Score of 13 should have triggered an updated care plan per assessment instructions: " If Braden total is 16 or less, implement the Pressure Ulcer Prevention: High Risk (Adult) Plan of Care " . This had not been done.

Review of the documentation with the Director Corporate Safety, on 1/13/10 at approximately 1:00 p.m., confirmed that the Pressure Ulcer Prevention: High Risk (Adult) had not been done.

Based on record review and interview, the hospital failed to provide necessary updated information regarding 1 (#11) of 2 discharged patients. Findings include:

Medical record review of patient #11"s hospital transfer information dated 11/4/09 revealed that under the pressure sore section, only "stage II coccyx" was documented. This information did not include size or measurements, lacked a complete a description. The skin assessment at the Rehab Transfer facility documented on the "Illustration of documentation and measurements of skin areas" and "Nurses Notes" on 11/5/09 documented the following: Coccyx area: 1x1 open area, possible tunneling; Left buttock 9cm x 4 cm with dark sluffing necrotic tissue; Right buttock: 9cm x 6cm area with 5cm x 5cm granulation in center. Review of the hospital record with the Director of Quality on 1/13/10 confirmed that the nursing staff failed to document measurement of the patient's pressure sores.