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Based on staff interviews and review of clinical records and policy and procedure, it was determined the nursing department and staff:

1. Failed to ensure the registered nurse supervised and evaluated nursing care related to wound assessments, providing wound care according to physician orders and ensuring documentation in the clinical records was accurate for four (#2, #3, #4, #1 ) of ten sampled patients. This practice could lead to deterioration of the patient's health and well- being. (Refer to A0395)

2. Failed to assess/reassess patient wounds for 1 (#4) of ten sampled patients. This has a potential for an increase in infection both from the wound and chest tube site that could lead to deterioration of the patient's health and well- being. (Refer to A0395)

3. The facility failed to provide adequate supervision and evaluation of employee documentation resulting in falsification on clinical records related to patient assessments of wounds for 3 (#2, #3, #4) of ten sampled patients. This practice does not provide for the safe delivery of nursing care and services. (Refer to A0395).

4. Failure of the nursing staff to notify administration of discrepancies in documentation and patient/family concerns for four (#2, #3, #4, #1 ) of ten sampled patients. This practice does not allow for improvement in patient care and safety. (Refer to A0286).


The cumulative effect of the failure of the Nursing Staff to appropriately assess and evaluate the needs of the patient, failure to follow physician orders and falsification of patient assessments have resulted in the determination the facility is out of compliance with the Condition of Participation for Nursing Services.

Based on staff interviews, clinical record reviews and review of policies and procedures, it was determined the governing body failed to ensure nursing activities were tracked, analyzed for the causes of events and preventive actions were implemented to include feedback and learning throughout the hospital to ensure patient safety was maintained.

Findings included:

1. Patient #2 was admitted to the facility on 10/30/15. The initial nursing assessment dated 10/30/15 at 9:15 p.m. by the Registered Nurse (RN) revealed wounds present on admission included a surgical wound on the right lateral hip with 12 staples and a right lateral hip thigh with four staples. Registered Nurse (RN) assessment dated 10/31/15 at 8:20 a.m. revealed a surgical wound to the right lateral hip with 11 staples and one with 4 staples. There was no documentation as to why the change in the number of staples. RN assessments dated 10/31/15 at 8:32 p.m. and 11/1/15 at 8:00 a.m. and 7:57 p.m. revealed no documentation of the surgical wound or any type of wounds.

Registered Nurse, Wound Care Nurse #1, (WCN) conducted an initial wound assessment dated 11/2/15 at 3:43 p.m. which noted the lateral hip wound was redefined as a surgical wound. The documentation noted 7 and 12 staples. This was not consistent with prior numbers noted. The documentation noted a pressure ulcer to the left ear that was present on admission and a sacrum pressure ulcer that was present on admission.

WCN #1 documented the presence of a pressure ulcer on the left ear and sacrum as present on admission even though she completed this assessment on 11/2/15, approximately 3 days after the patient was admitted on 10/30/15. Review of physician documentation and RN assessment from admission on 10/30/15 to the time of WCN #1's initial assessment on 11/2/15 showed no evidence of these two pressure ulcers.

2. Patient #3 was admitted to the facility on 10/31/15. Review of the History & Physical dated 10/31/15 indicated no evidence of pressure sores being present, and the patient was alert and oriented.

The initial nursing assessment dated 11/1/15 at 12:43 a.m. by the RN revealed no open areas. Review of the nursing assessment dated 11/1/15 at 9:50 a.m. and 10:27 p.m. revealed no evidence of pressure sores.

Review of WCN #1's initial assessment documentation dated 11/2/15 at 4:14 p.m. noted a pressure ulcer on the sacrum that was unstageable, obscured by necrotic tissue and suspected Deep Tissue Injury (DTI). There was a pressure ulcer noted on the left medial thigh that was present on admission. It was a suspected DTI and obscured by necrotic tissue. WCN #1's documentation also noted a pressure ulcer to the left heel that was present on admission. It was unstageable and suspected DTI.

Review of physician documentation and RN assessment from admission on 10/30/15 to the time of WCN #1's initial assessment on 11/2/15 showed no evidence of these two pressure ulcers.

3. Patient #4 was admitted to the facility on 10/31/15. The initial nursing assessment dated 10/31/15 at 2:17 a.m. by the RN revealed a pressure ulcer to the right heel. It was non-blanchable, red and the skin was intact. Nursing assessment dated 10/31/15 at 9:00 p.m. and 11/1/15 for both shifts revealed no wound assessments.

WCN #1 documented an initial assessment dated 11/2/15 at 3:58 p.m. which noted the presence of a pressure ulcer on the right heel that was present on admission. It was unstageable and a suspected DTI. WCN #1 documented a pressure sore on the left malleolar as present on admission. It was unstageable and suspected DTI. WCN #1 documented a neuropathic/diabetic ulcer to the left anterior foot present on admission, obscured by necrosis-50% hard black eschar.

Physician documentation and RN assessment from admission on 10/31/15 to the time of WCN #1's initial assessment on 11/2/15 showed no evidence of a DTI pressure ulcer to the right heel and no evidence of a pressure ulcer to the left malleolar.

Review of patient #2, #3 and #4 revealed WCN #1 identified multiple wounds 48 to 72 hours after admission as present on admission and DTIs. Review of nursing and physician documentation did not reveal evidence of the wounds being present on admission.

Interview during the record reviews with the Risk Manager/Director Quality Management on 11/2 and 11/3/15 confirmed the above findings.

An interview with WCN #1 on 11/2/15 at approximately 1:55 p.m. was conducted with the Risk Manager/Director of Quality Management present. When questioned about wounds she documented as present on admission when there was no documentation of the wounds being present by the physician or nurse at the time of admission, WCN #1 responded that if a wound is a stage I, she will document it as a DTI to "protect" themselves if one should develop if a patient is not turned. WCN #1 also stated RNs may be told not to do an initial assessment by a Charge Nurse for wounds on admission because the wound care nurse will do the assessment.

Interview with Charge Nurse #2 on 11/2/15 at approximately 2:55 p.m. revealed nurses are frequently told to "do what you can" on initial assessment. The WCN will try to see the patient on the day of admission if possible.

Review of Policy and Procedure "Wound Assessment" H-WC 02-001 PRO dated 2/14 indicated the RN would complete a wound care assessment at the time of admission. An assessment of "major" wound would be done by the Wound Care Coordinator or designee within forty eight hours of admission.

4. Patient #1 was admitted to the facility on 8/6/15. Review of the admission wound assessment showed the presence of a chest wound, pressure ulcer on the sacrum 8 x 2 cm Stage III without drainage.

Physician admission orders dated 8/7/15 included orders to apply Comfortfeel every three days to the sacrum and cleanse with pericare. The orders included the left chest tube was to be cleansed and the dressing was to an ostomy bag and change the bag if leaking.

Interview with the Risk Manager/Director of Quality Management on 11/2/15 at approximately 3:05 and review of nursing documentation from 8/7/15 through discharge on 9/29/15 revealed no evidence of the the sacral wound or left pleural tube wound care being performed or assessments being conducted per physician orders.

The interviews with the Risk Manager/Director of Quality Management and Chief Clinical Officer on 11/2/15 at approximately 4:00 p.m. revealed no knowledge of the above practice or the discrepancies between the RN and WCN assessments.

Patient #4's clinical record review noted the patient left the facility on 9/29/15 Against Medical Advice (AMA). Review of the AMA form dated 9/29/15 indicated the reason the patient left AMA was due to questionable care, previous lack of response resulting in a cardiac arrest.

Interview with the Risk Manager/Director of Quality Management on 11/2/15 at approximately 1:10 p.m. revealed she had no knowledge of the above. The nurse caring for the patient failed to notify a supervisor or risk management of the concerns and documentation.

Based on staff interviews, clinical record reviews and review of policies and procedures, it was determined the registered nurse failed to supervise and evaluate nursing care related to wound assessments, providing wound care according to physician orders and ensuring documentation in the clinical records was accurate for four (#2, #3, #4, #1 ) of ten sampled patients.

Findings included:

1. Patient #2 was admitted to the facility on 10/30/15. Review of the History and Physical (H&P) dated 10/30/15 indicated the patient was status post a hip fracture repair of the right leg.

The initial nursing assessment dated 10/30/15 at 9:15 p.m. by the Registered Nurse (RN) revealed wounds present on admission included a surgical wound on the right lateral hip with 12 staples and a right lateral hip thigh with four staples. Registered Nurse (RN) assessment dated 10/31/15 at 8:20 a.m. revealed a surgical wound to the right lateral hip with 11 staples and one with 4 staples. There was no documentation as to why the change in the number of staples. RN assessments dated 10/31/15 at 8:32 p.m. and 11/1/15 at 8:00 a.m. and 7:57 p.m. revealed no documentation of the surgical wound or any type of wounds.

Registered Nurse, Wound Care Nurse #1, (WCN) conducted an initial assessment dated 11/2/15 at 3:43 p.m. which noted the lateral hip wound was redefined as a surgical wound. The documentation noted 7 and 12 staples. This was not consistent with prior numbers noted. The documentation noted a pressure ulcer to the left ear 4 x 2.2 centimeters (cm) that was present on admission and a sacrum pressure ulcer 4.5 x 4 x 1.6 cm that was present on admission.

The WCN #1 documented the presence of a pressure ulcer on the left ear and sacrum as present on admission even though this initial assessment was conducted on 11/2/15, approximately 3 days after the patient's admission on 10/30/15. Review of physician documentation and RN assessment from admission on 10/30/15 to the time of WCN #1's initial assessment on 11/2/15 showed no evidence of these two pressure ulcers.

2. Patient #3 was admitted to the facility on 10/31/15. Review of the H&P dated 10/31/15 indicated no evidence of pressure sores being present, and the patient was alert and oriented.

The initial nursing assessment dated 11/1/15 at 12:43 a.m. by the RN revealed no open areas and bruised arms. Review of the nursing assessment dated 11/1/15 at 9:50 a.m. and 10:27 p.m. revealed no evidence of pressure sores.

Review of WCN #1's initial assessment dated 11/2/15 at 4:14 p.m. noted a scabbed wound to the right elbow, right knee and left lower leg that were present on admission. A pressure ulcer on the sacrum that was present on admission. It was 8 x 1 x 0.1 cm, unstageable, obscured by necrotic tissue and suspected Deep Tissue Injury (DTI). It was also documented necrotic tissue type and amount was none visible. There was a pressure ulcer noted on the left medial thigh that was present on admission. It measured 1.5 x 3.5 cm, unstageable, suspected DTI and obscured by necrotic tissue. It was also documented necrotic tissue type and amount was none visible. WCN #1 documentation also noted a pressure ulcer to the left heel 3.4 x 5 cm that was present on admission. It was unstageable and suspected DTI. It was obscured by necrotic tissue. It was also documented necrotic tissue type and amount was none visible.

Review of physician orders 11/2/15 (recommendation from WCN #1) revealed orders to apply Skin Prep to the right and left heel and left ankle/foot area, Apply Baza Critic A to the sacrum four times a day and as needed. Apply skin prep to the scabbed areas.

Review of physician documentation and RN assessment from admission on 10/30/15 to the time of WCN #1's initial assessment on 11/2/15 showed no evidence of these pressure ulcers.

3. Patient #4 was admitted to the facility on 10/31/15. Review of the H&P dated 11/1/15 indicated no evidence of pressure sores being present and the patient was alert and oriented. The documentation noted the patient was status post amputation of the left great toe with a plan for wound care. There was no documentation of any other wound.

The initial nursing assessment dated 10/31/15 at 2:17 a.m. by the RN revealed a pressure ulcer to the right heel. It was non blanchable, red and the skin was intact. The left foot dressing was intact. Nursing assessment dated 10/31/15 at 9:00 p.m. and 11/1/15 for both shifts revealed no wound assessments.

Review of WCN #1's initial assessment documentation dated 11/2/15 at 3:58 p.m. noted the presence of a pressure ulcer on the right heel that was present on admission. It was unstageable DTI that was resolved and healed. The documentation indicated the surgical wounds of the left great and second toes were healed. WCN #1 documented a pressure sore on the left malleolar as present on admission. It was 5 x 6 cm, unstageable, suspected DTI and obscured by necrotic tissue. It was also documented necrotic tissue type and amount was none visible. WCN #1 documented a neuropathic/diabetic ulcer to the left anterior foot present on admission, 12 x 7 cm, obscured by necrosis-50% hard black eschar.

Review of physician orders 11/2/15 (recommendation from WCN #1) revealed orders to paint the left foot with betadine, skin prep to the right and left heel and ankle area.

Review of physician documentation and RN assessment from admission on 10/31/15 to the time of WCN #1's initial assessment on 11/2/15 showed no evidence of the two pressure ulcers.

Review of patient #2, #3 and #4 revealed multiple wounds were identified by WCN #1 48 to 72 hours after admission as having been present on admission and DTIs. Review of nursing and physician documentation did not reveal evidence of the wounds being present on admission.

Interview during the record reviews with the Risk Manager/Director Quality Management on 11/2 and 11/3/15 confirmed the above findings.

Interview was conducted with WCN #1 on 11/2/15 at approximately 1:55 p.m., with the Risk Manager/Director of Quality Management present. When she was questioned about wounds she documented as present on admission in the absence of documentation of the wounds by the physician or nurse on admission, WCN #1 responded that if a wound is a stage I, she will document it as a DTI to "protect" themselves if one should develop if a patient is not turned. WCN #1 also stated RNs may be told not to do an initial assessment by a Charge Nurse for wounds on admission because the wound care nurse will do the assessment.

Interview with Charge Nurse #2 on 11/2/15 at approximately 2:55 p.m. revealed nurses are frequently told to "do what you can" on initial assessment. The WCN will try to see the patient on the day of admission if possible.

Review of Policy and Procedure "Wound Assessment" H-WC 02-001 PRO dated 2/14 indicated the RN would complete a wound care assessment at the time of admission. An assessment of "major" wound would be done by the Wound Care Coordinator or designee within forty eight hours of admission.

4. Patient #1 was admitted to the facility on 8/6/15. Review of the H&P dated 8/7/15 noted the patient had a left pleural tube in place with a drainage bag and was alert and oriented. There was no documentation of any other wounds or pressure sores.

The initial nursing assessment dated 8/6/15 at 10:43 p.m. noted the pulmonary assessment did not mention the presence of the pleural tube or if the patient was on oxygen. Review of the admission wound assessment showed bilateral upper and forearm abrasion, the presence of a chest wound, pressure ulcer on the sacrum 8 x 2 cm Stage III without drainage.

Physician admission orders dated 8/7/15 included orders to apply Comfortfeel every three days to the sacrum and cleanse with pericare. The left chest tube was to be cleansed and the dressing was to an ostomy bag and change the bag if leaking.

WCN documentation dated 8/8/15 noted the sacrum had DTI and the presence of a left chest tube.

Interview with the Risk Manager/Director of Quality Management on 11/2/15 at approximately 3:05 and review of nursing documentation from 8/7/15 through discharge on 9/29/15 revealed no evidence of the the sacral wound or left pleural tube wound care being performed or assessments being conducted per physician orders. The nursing documentation did not consistently show the amount of oxygen the patient was receiving.