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Based on hospital documents and medical record review, and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. This occurred in one (Patient #1) of ten patient medical records reviewed.

In order to determine the patient's needs/care required, accurate initial and ongoing assessments of the patient's health status/condition, interventions provided and response to interventions must be performed.

Findings:

1. The nursing assessments from admission, 01/20/15, through 01/24/15 recorded Patient #1 did not have any skin disruptions or pressure areas. By 02/08/15, nursing notes reflected the patient had a Stage III pressure ulcer.

Nursing notes on 01/24/15 at 0900 and 1100 documented the patient refused to turn and kept wanting to put a pillow under her buttocks.

On 01/25/15 at 0800, the nursing notes documented Patient #1 had a purple discoloration on the left buttock, but that the skin was intact. A "foam" dressing was applied.

Nursing notes on 01/26/15 documented a foam dressing was over the patient's sacral area.

Nursing notes at 1400 on 01/29/15 identified a Stage I disruption on the patient's left buttock as an intact purple/maroon/dusky red area and was left open to air.

On 02/03/15 at 0530, the nurse documented the patient had a partial thickness open area along with the purple/maroon localized area of intact skin pressure area. Zinc oxide was applied to the area.

On 02/04/15 at 2000, the nurse documented the partial thickness area was bleeding.

On 02/08/15 at 1800, the nurse documented the patient had a Stage III pressure ulcer. The nurse described the area as black with a small amount of bloody drainage with a moderate odor.

2. None of the nursing skin assessment notes contained dimensions of the pressure areas. No dimensions of the patient's skin pressure areas were charted until the wound care nurse saw the patient on 02/09/15 at 1111. At that time the wound care nurse charted the patient had a large excoriation on the buttocks and sacrum that measured 24 centimeters (cm) by 24 cm by 0.2 cm deep.

3. Nursing notes did not contain evidence the physician was notified of the changes in the patient's skin condition. No physician orders for wound care team evaluation were written until 02/08/15 at 1615. Staff C and D told the surveyor that nurses did not need a physician's order for the "foam" dressing, barrier cream or zinc oxide.

4. A specialty air chamber mattress, Alt. Stage IV 2000, was not ordered until 02/16/15 at 1018.

5. The hospital has a protocol for wound prevention, titled "Save the Skin Manual". Although nursing staff followed the protocol, the manual does not identify high risk patient and contacting the wound care nurse until the patient has a Braden scale of 12 or below. At the time of review on 03/12/15, the patient's Braden scale had not been below 13.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure medical records were complete, filed and retained. This occurred in one (Record #1) of ten medical records reviewed.

Findings:

The medical record documentation on 02/11/15 at 1435, by the surgeon, Staff I, that a verbal surgical consent had been obtained from the patient's son for a tracheotomy to be performed on Patient #1. Staff I documented at 1443, Staff I documented that the patient refused to have the procedure (as evidenced by the patient shaking head "no") and he did not feel it was ethical to proceed.

Patient #1's medical record did not contain this consent form. This was confirmed with Staff C at the time of review on the afternoon of 03/03/15.

On 03/04/15 at 1220, Patient #1's son told the surveyor that he gave verbal consent for a tracheostomy to be performed on the patient, but then called on the evening of 02/11/15 and withdrew the consent. He stated that he talked with a nurse, indicated Staff G by name, and she told him she would put the consent in the recycle/shed box.

On 03/04/15 in the afternoon, Staff G told the surveyors that she had talked with the son three times on 02/11/15 and confirmed he wanted to withdraw the consent for the tracheotomy. She stated she did not know what happened to the consent. She stated she did not remember taking the consent out of the medical record. She stated she did not document the conversation with the son in the medical record.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure consents were signed by authorized individuals. This occurred in one (Record #1) of eight current patient medical records reviewed.

Findings:

The hospital's informed consent policy, PR13, with a revision date of July 2012, listed those authorized to give informed consents when the patient is incapacitated. The policy identified that the person(s) named in the Health Care Proxy portion of the the patient's "...Advanced Directive (Oklahoma State Statute 63-3101.1 et.seq.)..." was authorized to execute informed consents for the patient.

Patient #1
According to the medical record, Patient #1 did not have a Power of Attorney for Healthcare; however, the Oklahoma Advanced Directive for Health Care, dated 01/15/15, contained a Healthcare Proxy that recorded that if the patient was unable to make healthcare decisions, her son was authorized to do so. The Healthcare Proxy also specified one named daughter was authorized as the alternative.

The medical record contained two consents that were not executed/signed by either the patient or an authorized representative. According to the documentation, the consents were obtained as telephone consents from the daughter-in-law.

The consent findings were reviewed and confirmed with Staff C at the time of review on the afternoon of 03/03/15 and again on the afternoon of 03/04/15 with administrative staff.