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Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the nursing staff failed to ensure the wound care policy and procedures were followed for accurate documentation and measuring of wounds in one of ten medical records reviewed (MR1).

Findings include:

Review on April 12, 2012, of the facility's "Pressure Ulcers: Braden Scale for Predicting Pressure Ulcer Risk and Prevention and Care [D-34] policy," last revised June 2011, revealed "III. Policy and General Instructions: A. Skin Assessments ordinarily are performed on admission of all patients and daily, or more frequently as clinically appropriate. ... G. Pressure Ulcer documentation data includes Braden Scale score, ulcer location, ulcer size in cm (centimeters), ulcer stage, color of ulcer tissue, amount and type of drainage, and associated pain."

Review of MR1 on April 12, 2012, revealed the following: The patient was admitted to the facility on January 1, 2012, and discharged on January 25, 2012. Review of the skilled nursing facility transfer documentation in MR1 revealed the patient had a "Right ischial ulcer and sacral ulcer." There was no further documentation regarding staging or measurements for these ulcers.

The documentation in the Skin Care Plan did not address each individual pressure ulcer regarding the healing status. The following documentation was noted for all pressure ulcers: "Tissue Integrity: elasticity IER (in expected range); sensation IER, hydration IER, skin color IER, skin intactness tissue perfusion nutrient intake food / fluid intake[e] reduced IWL [this abbreviation is unknown] lack of pressure on prominence". Documentation regarding wound healing was noted as "skin approximatn [approximation] granulation epithelializan [epithelization] resolution of: serosang [serosanguinous] drainag [drainage] skin erthema [erythema] skin temp [temperature] elev [elevated] macerated skin".

The nursing staff did not consistently document the location of the pressure ulcers. On January 1, 2012, The Skin Care Plan assigned Skin Disorder number one to buttocks and thigh and Skin Disorder number two to the gluteal cleft.

The Nursing Staff flowsheet for January 1, 2012, revealed the pressure ulcer indicated as Site Number one was the gluteal cleft and Site Number two was the left ischium.

On January 1, 2012 at 23:42, there was a free text note on the Nursing flow sheet documenting a 2 cm slit in the genital area. During the remainder of the hospitalization the genital area was documented as swollen or reddened. There was no further documentation noting the 2 cm slit.

The Nursing Flow Sheet for January 4, 2012, revealed the pressure ulcer Site Number one was gluteal cleft and left ischium.

The Nursing Flow Sheet for January 6, 2012, on the day and evening shift, revealed the pressure ulcer Number two was located on the back and sacrum.

The Nursing Flow Sheet for January 6, 2012, on the night shift, revealed the pressure ulcer Number two was the left ischium.

The Nursing Flow Sheet for January 9, 2012, on the day shift, revealed the pressure ulcer Number one was located on the buttocks and thigh.

The Nursing Flow Sheet for January 11, 2012, on the day and evening shifts, revealed the pressure ulcer Number one was located on the buttocks and ischium.

The Nursing Flow Sheet for January 11, 2012, on the evening shift, revealed the pressure ulcer Number one and Number two were the gluteal cleft.

The Nursing Flow Sheet for January 13, 2012, on the evening shift, revealed the pressure ulcer Number one was located at the gluteal cleft and the left heel.

The Nursing Flow Sheet for January 14, 2012, on the day shift, revealed the pressure ulcer Number one was located at the ischium, left heel, buttocks, and thigh.

The Nursing Flow Sheet for January 14 and 15, 2012, on the night shift, revealed the pressure ulcer Number one was the gluteal fold.

The Nursing Flow Sheet for January 16, 2012, on the evening shift, revealed the pressure ulcer Number one was the gluteal cleft, right lateral ischium, and left heel. Pressure ulcer Number two was the left lateral ischium.

The Nursing Flow Sheet for January 17, 2012, on the day and evening shifts, revealed the pressure ulcer Number one was the left lateral ischium.

The Nursing Flow Sheet for January 18, 2012, on the day shift, revealed the pressure ulcer Number one was the buttocks and sacrum.

The Nursing Flow Sheet for January 19, 2012, on the day shift, revealed the pressure ulcer Number one was the gluteal cleft, left lateral ischium, and left heel. Pressure ulcer Number two was the right lateral ischium.

The Nursing Flow Sheet for January 22, 2012, on the day shift, revealed the pressure ulcer Number one was the left gluteal cleft, left lateral ischium, and left heel. Pressure ulcer Number two was the right lateral ischium.

The Nursing Flow Sheet for January 24, 2012, on the day shift, revealed the pressure ulcer Number one was the sacrum, left lateral ischium, right gluteal cleft, and left heel. Pressure ulcer Number two was the ischium. Pressure ulcer Number three was the midline of the sacrum.

Further review of MR1 revealed one entry for the documentation of wound measurement by the nursing staff. On January 5, 2012, EMP2 documented "there was a history of left ischial ulcer and sacral/gluteal cleft ulcer." EMP2 documented measurements as follows: "L (left) ischial 1.3 x 0.3 x 1.0 cm (centimeters) with 2.7 cm x 11 o'clock tunnel."

Interview with EMP1 on April 12, 2012, at approximately 3:30 PM, confirmed the nursing staff did not follow their policy and procedures for wound documentation and measurements for MR1.