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A. Based on Facility policy, clinical record review and staff interview, it was determined in 3 (Pt. #s 1,2,3)of 10 clinical records reviewed, the CAH failed to ensure the responsibility of preventing skin breakdown was implemented by all nursing staff and caregivers.

Findings include:

1. Facility policy #MS3-5-360 indicates:
A risk assessment and skin assessment will be completed and documented on the nursing assessment at the time of admission on all patients.
A Braden Scale Assessment will be used for predicting ulcer risk and is to be completed by the RN on admission.
A skin assessment is performed and will include assessment of skin color texture and turgor.
Any stage I or higher will be documented and photographed after proper consent is obtained on admission and at discharge.
Wound care and preventative interventions will be reflected in the plan of care.
If a patient develops skin breakdown after admission to the hospital, an occurrence report must be filled out.

2. Pt. #1 was transferred directly to the SNF swing- bed on 05/18/10 with the diagnosis of post status right hip repair after a fall. Documentation indicated that Pt. #1 had a right hip incision with significant drainage upon arrival. There was no documentation to indicate a full body skin assessment was completed on admission to assess the risk and interventions necessary to prevent pressure ulcers. Documentation of a Braden scale assessment was utilized to determine predictability of potential ulcers and Pt. #1 was leveled at high risk. There was no documentation, other than the incisional wound, to indicate any type of skin breakdown on admission. On 05/24/10 documentation indicated ulcerative areas (blisters) were noted on Pt. #1s right heel. Documentation indicated on 05/27/10 that Pt. #1 had ulcerative areas measured at Stage II to his buttocks. Pt. #1 had documented wounds below his right hip, to his buttocks and blisters on his right heel that were not previously assessed on admission. There were no photographs of the wounds taken on admission or at discharge and no occurrence reports completed after the development of the wounds.

3. Pt. #2 was admitted to the Hospital on 01/20/10 with the diagnosis of renal insufficiency. The ED (Emergency Department) skin assessment indicated that Pt. #2's skin was intact and normal. The initial nursing assessment indicated that Pt. #2 had a rash on his head. On 01/22/10 orders were received for "wound care per home health and to apply Exoderm every three days." Another order indicated the left heel should be "cleansed with warm water and soap and pat dry." There was no documentation to indicate Pt. #2 had a chronic heel wound prior to the orders received on 01/22/10.

4. Pt. #3 was admitted to the Hospital on 10/13/09 with acute myocardial infarction. There was no documentation to indicate there were any skin problems on admission. On 10/15/09 a Stage I ulcerative area was found and documented on the patient's buttocks and an air mattress was ordered. Other documentation indicated that "ointment" was applied. There was no physician's order for the ointment.

5. The above findings were verified with the Director of Nursing on 07/06/10 at 2:00 pm.