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Based on staff interview and clinical record review, the facility failed to ensure the registered nurse evaluated the nursing care related to a pressure sore for 1 of 10 sampled patients (Patient #5) out of a total census of 380.

Findings include:

During this visit from 02/24/10 through 03/02/10, a review of Patient #5's clinical record was reviewed. According to the record, this patient was admitted to the facility on 01/25/10, and was still currently in the facility. Upon admission, the patient was identified with a pressure ulcer on the coccyx, which was covered with a dressing. This area developed into a Stage II pressure sore (now open through at least one layer of skin) on 02/06/10. The clinical record stated the hydrocolloid dressing was changed on 02/01/10, 02/07/10, and 02/16/10. The registered nurse progress notes on those dates lacked an evaluation of the pressure sore (a description of depth, width, length, drainage, color). An interview with the wound care nurse (Staff on 03/01/10 at 10:10 AM revealed the facility practice is to change hydrocolloid dressings every seven days and document an assessment of the pressure sore at that time. This was verified with Staff H (Clinical Manager of the Medical Intensive Care Unit) on 03/01/10 at 10:20 AM. Staff A and B stated the facility policy is for the registered nurse to assess and document a description of the pressure sore at least every 7 days.

A review of Policy File NC-A 52.0 stated nursing staff must document the description and location of the impaired skin integrity in the progress notes, and address the ulcer on the plan of care. The policy also stated: For a Stage I the affected area should be observed at least once every 8 hours, and a Stage 2 pressure ulcer should be observed with each dressing change.


Staff A verified the registered nurses who changed Patient #5's dressings on the aforementioned dates did not follow the facility policy for assessing and documenting the pressure sore status.