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Based on clinical record review and staff interview the Registered Nurses (RNs) failed to supervise and evaluate the nursing care provided to 1 of 3 sampled patients (#1). The facility's policy regarding assessment was not followed.

The Findings Include:

Review of the clinical record for patient #1 revealed the patient presented in the Emergency Room (ER) on 12/31/09 at 11:34 AM with complaints of chest pains, shortness of breath, fever, chills, and Congestive Heart Failure (CHF) secondary to Aortic Valve Replacement (surgery done on 12/18/09).

Review of the "Primary Survey Assessment Record" dated 12/31/09 revealed an inspection of the patient's skin and a pressure ulcer screen were performed and documented by an RN in the ER at 11:34 AM. The record documents that the patient has a mid sternal scar, scar to the anterior aspect of the left thigh, and edema to both legs. A Braden Scale assessment completed for Skin integument scored the patient 19 (score between 19 and 23 indicates the patient is at low risk for developing pressure sores).

The Skin Pressure Points Record dated 12/31/09 (in the ER) document a 2 mm distal opening on the patient's old sternal incision and a Stage II pressure sore on the patient's Coccyx. The assessment in the record did not include an evaluation of the wound's measurement, wound bed, the peri wound area, presence of infection, wound margin, exudate, tracking/tunneling or odor, nor is there evidence the physician was informed of the 2mm distal opening at the sternal (12/18/09 incision wound), or of the stage II pressure sore on the patient's Coccyx.

The patient was transferred to telemetry on 12/31/09. A review of the physician admission order dated 12/31/09 revealed no orders for the care of the patient's sternal wound and Stage II pressure sore which was documented to be on the patient's coccyx. There was no documentation to substantiate that the ER nurses communicated the status of the patient's sternal wound or stage 11 pressure sore during transfer from the ER to the Telemetry unit.

Record review revealed that while on the telemetry unit on 01/01/10 the patients' pressure sore was not assessed and/or revaluated by an RN to ensure the patient received the appropriate wound care. On 01/01/10 at 8:00PM, the nurses notes document: "Midline chest incision dressing at distal end dry and intact. Small hole located under dressing."

A review of Dr S--------consultation notes dated 01/01/10 confirmed that the patient had an elevated White Blood Cell count (WBC), and that after admission the patient's Sternum drained foul smelling fluid. Upon examination, Dr S------- noted that the patient had a (1) cm opening with purulent drainage on the inferior aspect of the sternal incision. Blood and wound cultures were done and the results indicated that the patient had an infected sternal wound with gram positive Cocci. Treatment was initiated with Vancomycin and Zosyn Antibiotics. The plan was to obtain consent for surgery from the patient to perform sternal exploration.

A review of the physician history and physical record dated 01/01/10 revealed no documentation that the patient had a Stage 11 pressure ulcer.

Review of the Altered Skin Integrity Flow Sheet dated 01/02/10 revealed the patient had a skin break on the left buttock (no mention of a Coccyx skin break). A photograph of the sacro/coccygeal area taken on 01/02/10 confirmed the skin break on the patient's left buttock. The sacral /coccygeal area was observed in the photo to be very red and irritated but not broken.

On 01/02/10 the patient was transferred to the cardiovascular Intensive Care Unit (CV-ICU) after undergoing surgery It was at this time that a physician order for the sternal wound care was documented.

On 01/03/10 at 9:45AM an order to implement the facility's: "Wound Protocol Plan of Care for Stage I and Stage II Pressure Ulcers" was documented by a physician assistant.
The order include:.Albumin/pre-albumin assessments, Nutrition consultation, Cleanse pressure sore with normal saline, Use barrier film around peri- wound, Apply sensicare if incontinent , Apply tegaderm if wound is dry or Verasive XC adherent dressing if there is moderate to heavy exudate. Vitamin C, Zinc and Arginade (protein) was also ordered to promote wound healing.

Review of the clinical record revealed a plan of care was not developed for the patient's sternal wound. A plan of care was not developed for the patient's stageII pressure sore on the left buttock until 01/02/10. The facility policy, "Patient Plan of Care" mandates the plan of care to be initiated within 24 hours of admission. (Please see deficient practice cited at A396 in this Report.)

The facility policy: Pressure Ulcer Assessment and Treatment specifies: Pressure ulcer wounds are assessed upon admission or when initially identified and with each dressing change. Emergency Department (ED) offers a point of entry and have a role in identifying pressure ulcers that are present on admission, through data collection and skin inspection and assessment. Identification should be documented in the ED Department specific form. If a patient is admitted with a pressure sore the physician should document "present on Admission " in the history and physical or progress notes. Presence of a pressure sore should be communicated at shift report and transfer and the physician should be notified. RNs should perform pressure ulcer assessments, obtain treatment orders, implement prevention and treatment protocols and plan of care and reassess the effectiveness of the plan.
The characteristics of the wound should be assessed and documented (location, stage, measurement, wound bed, peri wound, presence of signs of infection, wound margin, exudate, tracking/tunneling, odor, pain level.)

Based on clinical record review and staff interview the facility failed to ensure nursing staff develop and keeps current, a nursing care plan for 1 of 3 sampled patients (#1) related to the patients' sternal wound and pressure sore.

The Findings Include:

Review of patient #1's Primary Survey Assessment Record dated 12/31/09 revealed that an inspection of the patient's skin and a pressure ulcer screen was performed and documented by an RN in the ER at 11:34 AM. The record document that the patient had a mid sternal scar, scar to the anterior aspect of the left thigh and edema to both legs. The Skin Pressure Points Record dated 12/31/09 document a 2 mm distal opening on the patient's old sternal incision and a Stage II pressure sore on the patient's coccyx. The patient was transferred from the ER to Telemetry on 12/31/09.

Review of Dr S--------consultation notes dated 01/01/10 confirmed that after admission the patient's sternum drained foul smelling fluid and that the patient had an infected sternal wound with gram positive Cocci.
Review of the Altered Skin Integrity Flow Sheet dated 01/02/10 revealed that the patient had a skin break on the left buttock A photograph of the sacro/coccygeal area taken on 01/02/10 confirmed the skin break on the patient's left buttock to be a stage II pressure sore.

On 01/03/10 at 9:45 AM, an order to implement the facility's: "Wound Protocol Plan of Care for Stage I and Stage II Pressure Ulcers" was documented by a physician assistant.
The order include:.Albumin/pre-albumin assessments, Nutrition consultation, Cleanse pressure sore with normal saline, Use barrier film around peri- wound, Apply Sonicate if incontinent, Apply Tegaderm if wound is dry or Versive XC adherent dressing if there is moderate to heavy exudate. Vitamin C, Zinc and Arginase (protein) was also ordered to promote wound healing.

A review of the clinical record revealed a plan of care was never developed and kept current for the patient's sternal wound. A plan of care was not developed and kept current for the patient's stage II pressure sore on the left buttock until 01/02/10. Interventions as noted on this care plan (optimize nutrition, follow physician order for treatment and control moisture) were not implemented, nor was the the facility's: "Wound Protocol Plan of Care for Stage I and Stage II Pressure Ulcers.

Upon review it was noted that the facility Policy: "Pressure Ulcer Assessment and Treatment" specifies: The RN should perform pressure ulcer assessment, obtain treatment orders, implement prevention and treatment protocols, and plan of care, and reassess the effectiveness of the plan.

The facility Policy: "Patient Plan of Care" specifies that the plan of care is initiated within 24 hours by the RN and is based upon review of the admission assessment screens, data collected by the physicians and the physical assessment of the patient.