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Based on interviews, medical record review, observation and policy review, the facility failed to ensure ongoing assessment of patient needs and failed to follow physician orders (A0392). The facility failed to ensure the nursing staff develops, and keeps current, a nursing care plan for each patient (A0396). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients received safe care in accordance with physician orders and in accordance with the facility's policies. This had the potential to affect all of the facility's 152 active patients.

Based on medical record review, policy review and interview, the facility failed to ensure wound care was performed in accordance with physician ordered frequencies for one (Patient #10) of 10 medical records reviewed. This had the potential to affect all of the facility's 152 active patients.

Findings include:

The medical record review for Patient #10 revealed a wound care nurse was consulted and filed a progress note regarding Patient #10 on 09/01/16 at 8:40 AM. The wound care nurse documented Patient #10's coccyx had pink scarring. The area was red-blanchable with dried crusted area. The medical record contained an order to apply Sacral Mepilex to the coccyx area every 48 hours. The order was written on 08/31/16 at 3:45 PM. Wound care was documented as performed in the medical record as follows:
09/06/16 at 11:00 AM
09/02/16 at 6:18 AM
08/31/16 at 8:15 PM
08/31/16 at 4:45 PM
The medical record did not contain evidence of wound care being performed every 48 hours from 09/02/16 through 09/06/16.

The findings were shared with Staff A and Staff B on 10/19/16 at 1:42 PM and confirmed.

The facility's Registered Nurse job description was reviewed. The job description stated the registered nurse's principal job accountabilities include assessing patient's responses and reports adverse reactions and other pertinent information to the healthcare team and physicians. The registered nurse performs medical/surgical treatments accurately and according to procedures. The registered nurse transcribes and implements physician orders accurately.

Based on medical record review, interview and policy review, the facility failed to ensure preventative measures were taken to prevent skin breakdown in accordance with the care plan for one patient (Patient #9) of 10 medical records reviewed. The facility failed to monitor one patients with (Patient #9) in accordance with the care plan and physician orders. The facility failed to ensure one patient's care plan (Patient #4) was current in accordance with the facility's policy. This had the potential to affect all of the agency's 152 active patients.

Findings include:

1. The medical record review for Patient #4 revealed Patient #4 was assessed as having the following Braden Scale scores:
10/15/16 at 7:10 PM = 15
10/16/16 at 9:50 AM = 15
10/17/16 at 11:10 AM = 14
10/17/16 at 11:43 PM = 15
10/17/16 at 4:31 AM = 12
10/18/16 at 11:07 AM = 15
10/18/16 at 2:00 PM = 15
10/19/16 at 5:18 AM = 15
10/19/16 at 12:14 PM = 14

The medical record review revealed the problem of Skin Integrity was not added to the Plan of Care until 10/18/16.

The findings were shared with Staff A on 10/18/16 at 10:53 AM and confirmed.

2. 1. The medical record review of Patient #9 revealed Patient #9 was admitted to the facility on 08/26/16 for complaints of shortness of breath and abdominal pain. Patient #9 was discharged to a long-term acute hospital on 09/07/16.

On 08/26/16, the problem of Hemodynamic Status was added to the care plan. Interventions on the care plan included to monitor Patient #9's weight.

The medical record contained an order for daily weights on 08/26/16 at 3:15 AM. The medical record did not contain evidence of the facility obtaining Patient #9's weights on 08/27/16, 08/28/16, 08/29/16 and 08/30/16.

3. The nursing care plan for Patient #9 from 08/26/16 included the problem of impaired mobility/activity intolerance. Interventions were listed to obtain the goal of maintaining mobility/activity at optimum level for Patient #9. An intervention included to turn Patient #9.

The problem of risk for impaired skin integrity was added to the care plan on 08/29/16. Interventions on the care plan included to turn Patient #9.

The medical record contained an order for Patient #9 to be up as tolerated on 08/26/16 at 3:15 AM. On 08/29/16 at 2:17 PM. the medical record contained an order for nursing to turn or assist with turn every two hours if patient is unable to turn self and to remind Patient #9 to turn if necessary.

The medical record review revealed Patient #9 was first assessed as having the following wounds:
A. Skin tear to mid coccyx first assessed on 08/30/16 at 1:45 PM
B. Skin tear to right inner buttocks first assessed on 08/30/16 at 1:48 PM
C. Blister to right buttocks first assessed on 08/29/16 at 9:00 AM
D. Skin tear to posterior scrotum first assessed on 08/30/16 at 11:00 PM

The medical record did not contain a measurement of Patient #9's wounds after 08/31/16. On 08/31/16 at AM, Patient #9's skin tear to the mid coccyx was measured as length-1cm, width - 0.3cm. On 08/31/16 at 8:00 AM, Patient #9's skin tear to the posterior scrotum measured length - 0.5cm, width - 0.5cm. On 08/30/16 at 1:48 PM, Patient #9's skin tear to the right inner buttocks was measured as length - 0.2cm, width - 0.2cm, and depth - 0.1cm. On 08/30/16, a wound care nurse assessed Patient #9's wounds. The nurse documented the reason for the consult as blisters on right buttocks. The nurse documented the coccyx area has blanchable redness with darker skin, probably chronic. No open areas noted.

On 09/01/16 at 4:17 PM, a wound care nurse visited Patient #9. The nurse documented the coccyx wound was 3cm X 2cm X 0.1cm, with area of skin loss. Moderate amount of bright bleeding. Occurred over area of previous dark skin.

Patient #9 was seen by the wound care nurse on 08/30/16 and the wound care nurse reported the darkened area was attached at that time. The wound care nurse documented the underside of the scrotum had superficial skin loss. Plan was to apply Mepilex to coccyx wound and Zinc to scrotum.

The wounds were not measured again before Patient #9 was discharged.

The medical record contained an order to apply Sacral Mepilex to coccyx area every 72 hours and an order for Zinc Oxide 20% ointment two times a day. On 09/06/16 at 10:12 PM, a nurse documented the blister to the right buttocks, the skin tear to mid coccyx and skin tear to right inner buttocks as having small amount of foul purulent drainage, with a strong odor. The medical record did not contain evidence of Patient #9's physician being notified regarding the change to the wounds.

The medical record contained documentation of Patient #9's activity and safety. The position of Patient #9 throughout his/her admission was as follows:
09/07/16
6:50 PM In bed, refused turn
1:57 PM Lying, left side, Repositioned
8:04 AM Lying, right side
4:07 AM Supine
1:57 PM Repositioned
12:00 AM Lying, right side

09/06/16
10:11 PM Lying, right side
9:53 PM In bed, Semi fowlers
7:23 PM In bed, Semi fowlers
3:00 PM In bed, Semi fowlers
9:30 AM Up in chair
8:05 AM Lying, left side
4:55 AM Lying, right side, repositioned
12:04 AM Repositioned

09/05/16
11:59 PM Lying, left side, turns self, Repositioned
8:00 PM Supine, Semi fowlers
6:04 PM Repositioned
5:17 PM Supine, Semi fowlers, Repositioned
12:27 PM Lying, Right Side
12:24 PM Lying, Right side, Semi fowlers
10:06 Pillow
10:00 AM Lying, Left side
8:15 AM Lying, Right side
4:18 AM Lying, Right Side
3:32 AM Lying, Left side
2:31 AM Lying, Right side
1:03 AM Lying, Right side

09/04/16
8:56 PM Lying, Left side, Repositioned
7:30 PM Supine, Semi fowlers
5:00 PM Chair
3:08 PM Chair
1:05 PM Lying, Left side
11:25 AM Lying, Left side, Repositioned
9:50 AM Chair
8:46 AM Chair
6:48 AM Chair, Repositioned
3:50 AM Lying, Left side
2:38 AM Lying, Right side, Repositioned
2:36 AM Lying, Right side

09/03/16
11:41 PM Repositioning refused, Lying, Left side
8:40 PM Lying, Left side, Repositioned
6:34 PM Lying, Right side
4:50 PM Semi fowlers, Supine
8:00 AM Semi fowlers, Lying, Right side
5:58 AM Semi fowlers, Lying, Right side, Repositioned
4:45 AM Semi fowlers, Lying, Left side, Repositioned
3:34 AM Semi fowlers, Lying, Left side
12:00 AM Semi fowlers, Lying, Left side, Repositioned

09/02/16
10:00 PM Semi fowlers, Lying, Right side, Repositioned
8:00 PM Semi fowlers, Lying, Left side, Repositioned
6:00 PM Semi fowlers, Lying, Left side, Repositioned
4:00 PM Semi fowlers, Lying Left side, Repositioned
2:00 PM Semi fowlers, Supine, Repositioned
12:00 PM Semi fowlers, Lying, Left side, Repositioned
10:00 AM Semi fowlers, Supine, Repositioned
8:00 AM Semi fowlers, Lying, Left side, Repositioned
6:00 AM Semi fowlers, Lying, Right side
4:00 AM Semi fowlers, Lying, Right side
2:00 AM Semi fowlers, Lying, Left side
12:00 AM Semi fowlers, Lying, Left side

09/01/16
10:00 PM Semi fowlers, Lying, Right side
8:00 PM Semi fowlers, Lying, Left side
6:00 PM Semi fowlers, Lying, Right side, Repositioned
2:00 PM Semi fowlers, Lying, Right side, Repositioned
12:10 PM Semi fowlers, Lying Left side, Repositioned
10:00 AM Semi fowlers, Supine, Repositioned
8:05 AM Semi fowlers, Supine, Repositioned
5:58 AM Semi fowlers, Supine, Repositioned
4:00 AM Semi fowlers, Supine
2:00 AM Semi fowlers, Supine
12:00 AM Semi fowlers, Lying, Left side

08/31/16
11:35 PM Semi fowlers, Supine, unable to fully turn sue to dialysis
10:00 PM Semi fowlers, Supine, unable to fully turn due to dialysis
8:00 PM Lying, Left side, unable to fully turn due to dialysis
6:00 PM Lying, Left side
4:00 PM Semi fowlers
2:00 PM Semi fowlers, Lying, Right side
12:00 PM Semi fowlers, turns self
10:30 AM Semi fowlers, turns self
8:45 AM Semi fowlers, turns self, Repositioned
6:00 AM Lying, Right side
4:00 AM Lying, Right side
2:00 AM Supine
12:00 AM Lying, Left side

08/30/16
10:00 PM Lying, Right side, Repositioned
4:00 PM Lying, Left side
1:23 PM Lying, Right side
11:45 AM Chair
10:30 AM Chair
9:45 AM Refused by patient
7:45 AM Lying, Right side
5:00 AM Supine
3:16 AM Lying, Right side
1:21 AM Lying, Left side
1:09 AM Refused by patient, does not wish to sleep like on side
12:00 AM Supine

08/29/16
10:05 PM Lying, Right side
8:11 PM Repositioned
7:32 PM Supine
5:43 PM Chair, repositioning refused by patient
3:31 PM Chair, Repositioning refused by patient
2:06 PM Chair, Repositioning refused by patient
1:52 PM Chair
1:45 PM Chair
11:45 AM Chair
10:28 AM Chair
10:00 AM Chair
7:55 AM Lying, Right side
6:50 AM Turns self

08/28/16
8:30 PM Turns self, Lying, Left side
6:48 PM Turns self, Lying, Right side
4:23 PM Supine
10:17 AM Semi fowlers
8:49 AM Semi fowlers
8:01 AM Sitting, Commode

08/27/16
4:32 PM Supine
11:39 AM Chair
11:00 AM Supine, Turns self
8:17 AM Semi fowlers, turns self
4:29 AM Supine, turns self
4:00 PM Supine, turns self

08/26/16
11:15 PM Lying, Right side, turns self
7:30 PM Supine, turns self
4:45 PM Supine, turns self
8:00 AM Lying, Right side, turns self

The medical record did not contain documentation to show that Patient #9 was turned or encouraged to turn every two hours, per physician orders, as evidenced as above.

The medical record did not contain documentation to show that a waffle cushion or other pressure reducing device was used while Patient #9 was in the chair as required by the facility's Alteration in Skin Integrity policy.

The medical record did not contain evidence of the facility's staff following the facility's Alteration in Skin Integrity policy by only allowing Patient #9 to be up in the chair not greater than two hours as evidenced by the above.

The medical record did not contain documentation to show the facility's staff repositioned Patient #9 while Patient #9 was in the chair as required by the facility's Alteration in Skin Integrity policy, as evidenced above.

On 10/19/16 at 3:25 PM, Staff B confirmed the facility did not have a Safecare report regarding Patient #9's wounds.

4. The facility's Alteration in Skin Integrity policy (#S-13) was reviewed. The policy stated its purpose was to provide a safe environment for the nursing management of patients with potential or actual pressure ulcers and partial or full thickness wounds.
Preventative measures were listed as:
1. Post skin bundle signage with Braden Score of 18 or less.
10. Encourage maximum mobility and reposition the patient at least every two hours while in bed.
12. Evaluate patient for special support surface.
12. Keep bony prominences from direct contact using, at a minimum, pillows for relief.
14. Avoid positioning directly on any bony prominence (i.e. trochanter).
15. Avoid direct pressure to wounds.
18. "Self" is not acceptable when documenting repositioning. "Independent" is acceptable, but the patient must be prompted.

The policy listed preventative measures when in the chair as:
1. Position patient properly in chair.
2. Reposition at least every hour, if patient unable to shift weight himself or herself.
3. Have a patient shift weight every 15 minutes, if able.
4. Use pressure reducing devices for seating surfaces if available. Do Not use donut-type devices.
5. Limit chair time to no greater than two hours.
6. "Self" is not acceptable when documenting repositioning. "Independent" is acceptable, but the patient must be prompted.

The policy stated to notify the provider of the following:
1. Presence of pressure ulcer/wound following assessment
2. Elevated temperature
3. Abnormal lab data
4. Worsening of existing pressure ulcer/wound
5. Change in treatment is required based on assessment.

Documentation:
1. Braden Pressure Ulcer Rick Assessment on admission to hospital, upon transfer to unit, daily and with any change in condition
2. Skin assessment findings
3. Patient and family teaching
4. Preventative measures and interventions (i.e. specialty surfaces and protocols) initiated
5. Patient's response to interventions
6. Implementation of the SKIN Bundle
7. For multiple Stage I or II wounds, or a Stage III or IV wound, consult Inpatient Wound Care Coordinator.
8. If wound identified after admission assessment, complete Safecare Report.

5. The facility's Registered Nurse job description was reviewed. The job description stated the registered nurse's principal job accountabilities include assessing patient's responses and reports adverse reactions and other pertinent information to the healthcare team and physicians. The registered nurse performs medical/surgical treatments accurately and according to procedures. The registered nurse transcribes and implements physician orders accurately.

This deficiency substantiates Substantial Allegation OH00087128