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Based on review of the medical record, policy and procedure, and staff interviews, it was determined that the facility failed to supervise care and provide evidence of consistent wound assessment/wound care for 1 of 3 (#1) sampled patient records.

Findings were:

A review of the facility's policy entitled "Continuous Nursing Assessment Process", reviewed and revised 06/10, indicated that ongoing assessment/reassessments were conducted and reviewed by a Registered Nurse (RN) as warranted by the patient's condition, significant changes and at least every 24 hours. These assessments would include physical condition as warranted. The nursing staff would document in the patient's medical record the initial assessment, reassessments, the nursing care provided, the effectiveness of teaching, the outcome of nursing interventions, responses to interventions, and discharge activities. The nursing staff cooperated with physicians and other clinical disciplines when formulating patient care needs.

Review of the medical record for patient #1 revealed that the patient was admitted to the facility due to aggressive and combative behavior. The initial history and physical was completed within twenty-four (24) hours of admission. The physical exam did not reveal any rashes but did reveal that the patient had two (2) ecchymotic (bruising) regions of both upper extremities, a 1.3 centimeter skin tear on the right forearm, and a four (4) centimeter healing wound with scab formation on the left elbow. No signs of secondary bacterial infection were noted. The initial psychiatric evaluation revealed that the patient had a history of confusion, agitation, aggression, and inability to provide care to himself/herself.

Nursing flow sheets revealed that the patient remained disoriented and confused much of the hospital stay. The record indicated that the patient was viewed as a total care patient that needed assistance with all of his/her routine activities of daily living (ADLs - self help skills such as eating, bathing, toileting, dressing, and mobility).

Nursing documentation on flow sheets for day six (6), day seven (7), and day eight (8) of the hospital stay revealed that the patient had a stage 2 decubitus (an area of skin that broke open, blistered, or formed an ulcer) in the sacral/coccyx area. The record lacked evidence that the physician was notified or that treatment was initiated during this time. The record also lacked evidence of a nursing assessment of the sacral decubitus on the following two (2) days, day nine (9) and day ten (10). A physician exam, performed on day twelve(12) of this admission indicated that the patient had a 2 centimeter area of skin breakdown, not tender to palpation, with 8 to 9 centimeters of surrounding erythema (redness of skin caused by swelling of small blood vessels) on the coccyx/buttock region, assessed as a stage1-2 decubitus. Treatment was prescribed for Elastogel dressing to be applied and frequent rotation of the patient off the area.

An interview was conducted with the Risk Manager and the Director of Nursing at 10:30 a.m. on 08/23/11 in the Administrative Conference Room. The interviewees confirmed that the nursing documentation of day six (6), day seven (7), and day eight (8) of the hospital stay revealed that patient #1 had a stage 2 sacral decubitus. The interviewees also confirmed that there was no evidence of wound care assessment or treatment for the next two days, day nine (9) and ten (10) of the hospitalization. In addition, the interviewees confirmed that there was no evidence of a physician referral for wound assessment until day eleven (11) of the hospital stay, with the physician evaluation of the wound and treatment initiated on day twelve (12) of the hospital stay.