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Based on record and policy review and interview, the facility failed develop a plan to prevent pressure ulcer on the left foot of 1(SP #3) out of 3 sample patients (SP).

Findings include:

Record review showed sample patient (SP) #3 was admitted on 3/16/2019.

The review of the interdisciplinary plan of care showed nursing pressure ulcer interventions were initiated and documented on date 3/19/2019.

Review of Podiatry Consult History of Present Illness dated 4/4/2019 showed the patient (SP#3) has not had a history of wounds to the bilateral lower extremities. As far as they know the wounds are recent development. When removing the socks from the patient feet two wounds were found on the left foot. They are unsure how long wounds have been present.

On 5/1/2019 at 2:45 PM, interview with the Associate Nurse Manager of Outpatient Wound Care stated she saw the patient (SP #3) on 04/4/2019. She stated she won't be able to tell how long these left heel pressure injury, or the left plantar foot have been there. There has been off-loading, and use of bunny boots when she saw the patient. Her recommendations and some interventions to prevent pressure ulcers have been in place already.


Above acknowledged by the Associate Director of Quality/ Compliance Officer on 05/02/2019 at 3:30 PM.

The Policy "Pressure Ulcer Prevention", states Preventive Skin Care Interventions - Assess skin appearance and integrity every shift, paying particular attention to all bony prominences, including back of head, scapula, sacrum, and heels. Document the following on the appropriate medical record, abnormal assessment findings, and complications. This policy was not followed.

Based on record review and interview, the facility failed to ensure that the Prescriber was notified and that this notification was documented, in 1 (SP #3) out of 3 sample patients (SP) refusal to take medications.

Findings include:

Electronic record review of sample patient (SP) #3 Medication Administration Record (MAR) showed the patient refused 3/29/ 2019 at 05:36 AM, and 06:00 AM. Further record review revealed no documentation about notification of the Prescriber (Physician who ordered the medications) Amlodipine, and the Carvedilol.

On 5/1/2019 at 2:15 PM, the Associate Director of Quality/ Compliance Officer stated, moving forward, she already told the IT (Information Technician) staff to work on adding "notify Prescriber/ Physician" when patient refuses medication in order to increase compliance of staff in notifying the Physician who ordered the medication.

The Policy & Procedure "Medication Administration" Appendix 1 showed for inability to administer medication via route ordered, and patient refusal to take medications, intervention is to notify the Prescriber. This Policy was not followed.

Above acknowledged by the Associate Director of Quality/ Compliance Officer on 5/2/2019 at 3:30 PM.