The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST MARYS REGIONAL MEDICAL CENTER 1808 WEST MAIN STREET RUSSELLVILLE, AR 72801 Feb. 23, 2016
VIOLATION: NURSING SERVICES Tag No: A0385
Based on clinical record review, policy and procedure review and interview, it was determined the nursing staff failed to:


1. Assess and monitor four of four (#1, #2, #5 and #7) patients with identified impaired skin integrity in accordance with written procedures. As a result it could not be determined if the wounds had improved, remained the same or declined.


2. Assess, monitor and implement Lippincott's procedures for sequential compression devices (SCDs) for 11 of 11 (#1-#11) patients. The Chief Quality Officer informed the surveyor that the Lippincott procedure was being used at this hospital.


3. Identify the type of nutritional supplement and the amount of the supplement consumed to assist the Dietitian in assessing whether the nutritional goals were met for four of four (#1, #2, #5 and #7) patients with nutritional supplements.


4. Assure the listed interventions in the care plan were linked to the identified problem list for 11 of 11 (#1-#11) patients. It could not be determined with certainty which interventions belonged to which problem.


5. Assure the goal listed for integumentary was measurable for 6 of 6 (#3, #4, #8, #9, #10 and #11) patients identified to be at risk for skin impairment and 5 of 5 (#1, #2, #5 and #7) patients who were identified with skin impairment.


The failed practices did not assure patients were protected from potential injury; the nursing staff could determine when a wound had improved, remained the same or declined; the patient's nutritional goals were met to improve outcomes; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measureable to detemine if the problem continued or was resolved. The failed practice affected Patient #1-#11 and had the likelihood to affect all patients admitted to the facility.

See Tag A392 for details
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy and procedure review and interview, it was determined the nursing staff failed to:


1. Assess and monitor four of four (#1, #2, #5 and #7) patients with identified impaired skin integrity in accordance with written procedures. As a result it could not be determined if the wounds had improved, remained the same or declined.


2. Assess, monitor and implement Lippincott's procedures for sequential compression devices (SCDs) for 11 of 11 (#1-#11) patients. The Chief Quality Officer informed the surveyor that the hospital used Lippincott procedures.


3. Identify the type of nutritional supplement and the amount of the supplement consumed to assist the Dietitian in assessing whether the nutritional goals were met for four of four (#1, #2, #5 and #7) patients with nutritional supplements.


4. Assure the listed interventions in the care plan were linked to the identified problem list for 11 of 11 (#1-#11) patients. It could not be determined with certainty which interventions belonged to which problem.


5. Assure the goal listed for integumentary was measurable for 6 of 6 (#3, #4, #8, #9, #10 and #11) patients identified to be at risk for skin impairment and 5 of 5 (#1, #2, #5 and #7) patients who were identified with skin impairment.



The failed practices did not assure patients were protected from potential injury; the nursing staff could determine when a wound had improved, remained the same or declined; the patient's nutritional goals were met to improve outcomes; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measureable to detemine if the problem continued or was resolved. The failed practice affected Patient #1-#11 and had the likelihood to affect all patients admitted to the facility.



The findings were:



1. Sequential Compression Device (SCD)


A. During an interview with the Chief Quality Officer on 01/28/16 at 0830, he stated they did not have a policy and procedure for SCDs. He further stated the procedure would be based on the Lippincott Manual. At that time, a request was made for the procedure from the Lippincott Manual.


B. At 1320 on 01/28/16, the Chief Nurse Officer (CNO) presented the Lippincott Manual procedure for SCDs. Review of the procedure for Sequential Compression Therapy revealed:


1) "Sequential compression therapy shouldn't be used in patients with acute DVT [deep vein thrombosis] (or DVT diagnosed with [DIAGNOSES REDACTED]."


2) Special Considerations - "...Check the sleeves at least once each shift to ensure proper fit and inflation ...Assess the patient's skin under the sleeves at least every 8 hours to avoid skin breakdown. Assess the extremities for peripheral pulses, edema, changes in sensation, and movement at least once each shift."


3) Complications - "The most common complication of compression therapy is skin irritation, which usually results from sweating."


C. During an interview with the CNO on 01/28/16 at 1325, she confirmed the procedure from the Lippincott Manual. It was discussed that documentation did not reflect the above standards of care to which the CNO agreed.


2. Wound Care/Management Policy and Procedure


A. Review of the policy and procedure for Wound Management: Pressure Ulcer Risk Assessment/Prevention/Management (revised September 2011) revealed:


1) The policy stated to stage according to the National Pressure Ulcer Advisory Panel (NPUAP). There was no evidence the policy include the definition of a deep tissue injury defined by the NPUAP. The NPUAP defined a deep tissue injury as "A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald subsequent development of a Stage III-IV pressure ulcer even with optimal treatment."


2) Documentation requirements were:


a) "The pressure ulcer assessment will be documented initially on the RN [Registered Nurse] Admission Assessment and the PUSH [Pressure Ulcer Scale for Healing] Tool (Wound Management: PUSH), and each shift on the pressure ulcer documentation screen."


b) "Pressure ulcer reassessment will be completed weekly on Thursday, at discharge and PRN [as necessary] and documented on the PUSH Tool ..."


c) "All pressure ulcers stage I or greater should be photographed by the assessing RN upon admission or upon discovery, weekly on Thursday, at discharge and PRN. The photograph should be placed on a progress note in the chart ..."


d) "Pressure Ulcer Photography-

*Preserve the patient's privacy and dignity during the photo process

*Write the patient's name (or use a sticker) and the date photo taken on a disposable ruler

*Place ruler next to the ulcer so ruler and markings can be visualized in the camera with the ulcer taking up most of the picture

*If there are multiple wounds, identify sites separately

*Use a green or blue background for wound photography such as a blue plastic back disposable pad "


e) Documentation will include: "Site, Ulcer size (length, width, depth) in cm [centimeters], Exudate type (serous, bloody, serosanguinous, purulent), Exudate amount, Tissue Type, Stage (II-IV will be documented on the PUSH Tool in addition to the RN admission assessment and Wound Management: Pressure Ulcer), PUSH score, Pain and its management and dressing-document daily. "


B. Review of the Wound Management: Surgical/Non-surgical policy (September 2011) revealed it was to be used for wounds that could occur from friction, shearing, or trauma. Documentation was required initially, each shift, weekly, PRN and at discharge. The documentation was to include any risk factors, site, wound size (length, width, depth) in cm, exudate type, exudate amount, tissue type, response to treatment, pain and its management, dressing change on the Wound/Management: Non-Surgical Screen. Wounds were to be photographed by the assessing RN, upon admission or discovery, weekly on Thursday, at discharge and PRN.


3. Patient #1-Admission 01/10/16 (Current)


A. Review of the History and Physical dictated 01/10/16 and transcribed 01/11/16 revealed under "Addendum: "skin wound were examined with assistance of nurses, after the H & P [history and physical] was dictated. Patient has a stage 3 on sacrum with necrotic tissue but no active inflammation cellulitis changes. On left heel there is a decubitus with a necrotic tissue. On left posterior calf area there is significant skin breakage with few areas of cracking and oozing and some areas of pressure ulcers with black necrotic base. Patient will need wound care consult +/- surgery for debridement if wound care nurses cannot perform debridement. Will cover with duoderm on sacrum for tonight and have the leg and heels covered with non-adherent dressing and use curlix to wrap until seen in AM." There was no evidence of a full description of the pressure ulcers.


B. After the debridement by the physician on 01/12/16, the Post Op Diagnosis was Sacral decubitus-stage 3, R heel decubitus-Stage 3, L posterior calf, L dorsum of foot and L heel stage 4 with ischemic muscle, exposed tendon and exposed bone. Under findings it was written, Sacrum stage 3, R heel stage 4, LLE including heel and dorsum of foot stage 4 with ischemic, nonviable underlying tissue. There was no evidence the physician had sized each debrided wound.


C. Review of the General Nurse's Note 01/10/16 to 01/26/16 and Integumentary Assessment in the computer from 01/10/16 to 01/21/16 revealed inconsistencies as follows:


1) On admission (01/10/16), there was no written description of the wounds on the Integumentary Assessment. Pictures were taken but the location was not specified.


2) Review of the Integumentary Assessment 01/12/16 at 0745 under pressure ulcer revealed the right buttock had an unstageable ulcer. Under skin alteration, it was identified there was alteration on the legs bilaterally with necrotic tissue. There was no indication how many wounds there were and where they were located on the lower extremities bilaterally. Under Dressing Drains and Vacuum on 01/12/16 at 0835, reflected there was skin alteration on the left heel, Wound 3-coccyx, Wound 2-right heel, Wound 1-left lateral lower shin with the dressing clean/dry/intact. There was no description of the wounds as to the size, stage, the appearance of the wound bed, exudate type, exudate amount and tissue type.


3) Review of the General Nurse's Note dated 01/14/16 at 2007 identified the following wounds. The note did not address the stage, the appearance of the wound bed, exudate type, exudate amount and tissue type. There was no evidence to determine how the above locations corresponded to previous ulcer identifications. There was no evidence the right heel, sacrum and left lateral shin was reassessed.

a) Left leg on left upper calf 6.4 x 6.4;
b) Left lateral, upper wound lower leg, 2.2 x 1.6;
c) Left lateral ankle 1.6 x 2;
d) Left posterior calf 6.8 x 1.2;
e) Left heel 7.4 x 6.5;
f) Left medial calf 8.8 x 2.5;
g) Left top of foot 6.4 x 2.4;
h) Left medial base of great toe 2.5 x 2;
i) Great toe 0.5 x 0.3;
j) Let outer pinky toe 2 x 1; 11) Left buttocks 6.3 x 8.5 depth 2 cm; and
k) Right heel 4.2 x 2.1 cm.


4) Review of the General Nurse's Note dated 01/21/16 at 2100 revealed there was no evidence how these assessed locations corresponded to the ulcer locations identified on 01/14/16. There was no evidence if any ulcers had resolved or if there were new findings.

a) Left heel 8 cm x 2.5 cm pink edges, dark center with no exudate, Stage 3

b) Left calf wound number 2 proximal 2 cm by 4 cm by 2 cm depth dark color no exudate, Stage #3. There was no way to determine how this location corresponded to the location to the assessment done on 01/14/16 or if it was a new finding.

c) Left calf with 2 wounds circular with number 1 distal 2 cm by 2 cm by 3 cm depth dark tissue, Stage #3.

d) Left calf with a pyramid shape with dark covering measuring width 6 cm, length 9 cm with no exudate, Stage 2.

e) Right foot had a dried 1 cm wound with a dark covering.

f) There was no evidence right heel, sacrum, or the left lateral lower shin.


5) Review of the General Nurse's Note on 01/14/16 at 2007 and 01/21/16 at 2100 revealed the sites of the wounds on the left leg, heel and foot but did not mention right heel, sacrum, or which measurement addressed the left lateral lower shin.


D. Dressing Changes to wounds

1) A verbal order dated 01/10/16 at 1950 revealed "consult wound care for bilateral leg wounds and buttock. Consult general surgery for debrievemat of wounds. Duoderm to left buttock wound. Bilateral leg wound apply nonstick, nonadhesive dressing and wrap with Kerlex." The order does not specify the frequency for the dressing change or if it was a one time order.

2) Review of the General Nurse's Note dated 01/15/16 at 0958 revealed "Pt with no orders for dressing changes. Discussed with (Named Doctor). Orders obtained."

3) A telephone order dated 01/15/16 at 0958 revealed "Wounds to bilat (bilateral) legs: apply zeroform, fluff, a & Kerlix BID and PRN (as necessary). Wounds to sacrum zeroform, fluff and ABD (abdominal pad)." "Clarification wound to sacrum is change BID and PRN also."

4) Review of the General Nurse's Notes and Integumentary Assessment/Reassessment from 01/10/16 to 01/27/16 revealed there was no evidence of any dressing changes until 01/13/16. On 01/13/16, it was recorded a dressing change occurred to the left heel but no evidence of dressing change to any other wound. It was difficult to determine whether dressings were changed to each ulcer BID as the identification of the wounds were not consistently named the same and general terms were used to reflect dressing changes were performed.

E. Review of pictures of the wounds dated 01/10, 14, and 21/16 revealed Wound Management: Pressure Ulcer Risk Assessment/Prevention/Management (revised September 2011) was not adhered to as follows:

1) The pictures of the wounds were not identified by location therefore, it could not be determined which picture coincided with the written documentation.

2) The ruler used in the pictures was fuzzy and the markings were not visible.

3) There was no evidence with each picture that a green or blue background was used when the ulcers were photographed


F. There was no evidence the PUSH tool was used as required by policy and procedure to assist in determining an improvement or deterioration in the pressure ulcers.


G. Nutritional Supplements

1) Review of the nutritional assessment conducted on 01/11/16 revealed the patient had decubitus ranging from Stage 2 to a 3, the current diet order was cardiac, the patient had a poor appetite, the patient required 1825 kilocalories, 75-90 grams of protein, 1500 milliliters of fluid.


2) The follow-up notes dated 01/14, 15, 18, 21, 25 and 26/16 revealed the Dietitian did not address whether the kilocalorie and protein needs were met by consuming meal trays and supplements as ordered.


3) Review of the Intake and Output record for 01/10/16 to 01/26/16 revealed the supplements of Nepro, Propass, peaches were not recorded to assist the Dietitian in determining the kilocalories and protein consumed via each meal and each supplement.


H. Review of the Plan of Care of the Integumentary system revealed the goal/outcome was not written in measurable terms. The goal was to improve. It was difficult to ascertain what interventions were to be used to improve the outcome for the skin alteration. The format was to list all of the problems first and then list all interventions. The interventions were not linked back to a problem.


4. Patient #1-Admission 01/04/16 to 01/07/16


A. Review of the physician Discharge Summary dictated 01/07/16 revealed there were multiple discharge diagnoses which included but not limited to Peripheral vascular disease, Congestive heart failure, Atrial Fibrillation-[DIAGNOSES REDACTED]-permanent, Coronary artery disease-status post stent with a previous stent in 01/05/15, Non-ST elevated myocardial infarction and Chronic venous stasis dermatitis-both lower extremities.


B. SCDs


1) Review of the admission physician's order dated 01/04/16 at 2334 revealed the patient was admitted to the Intensive Care Unit and SCDs were ordered while in bed.


2) Review of the SCD documentation revealed it was recorded as Mechanical VTE (Venous Thromboembolism) Prophylaxis. The documentation reflected the SCDs were not worn due to procedure not wanted for 01/05/16 at 0900 to 01/06/16 at 0900. Then on 01/06/16 at 2100 to 01/07/16 documentation reflected the SCDs were applied bilaterally. There was no evidence the physician or nursing staff had assessed whether the patient had contraindications to wearing the SCDs such as peripheral vascular disease, serious arterial insufficiency, ischemic vascular disease, and heart failure. There was no evidence during the documented times the SCDs were worn that they were taken off every 8 hours and the skin inspected. There was no evidence of why the procedure was not wanted.


3) There was no additional documentation to support the SCDs were removed and the skin inspected as confirmed in the facility's submitted document on 02/22/16.


C. Wound Care/Management


1) Review of the handwritten verbal order dated 01/05/16 at 0921 revealed "Continue Zinc oxide topical ointment to wounds BID. The order entered into the computer 01/05/16 at 1000 read "Zinc oxide and Kerlix to LLE, right heel and bottom, change daily and prn." There was no evidence the orders were clarified as to whether it was to be BID or daily.


2) Review of Integumentary assessments from 01/04/16 to 01/07/16 reflected the following:


a) Left circumferential shin-partial thickness, blister, [DIAGNOSES REDACTED], peeling and SCD blister

b) Right posterior heel-partial thickness, bruise or contusion due to trauma and deep tissue injury.

c) Coccyx-full thickness, shear.

d) There was no assessment of length, width, depth, exudate type, exudate amount and tissue type and stage as required by policy and procedure. There was no evidence the deep tissue injury of the right heel was assessed if the area was firm, boggy, tender, etc.

e) There was no evidence pictures were taken of the patients identified skin conditions on admission or at discharge as required by policy and procedure.

2) Review of Integumentary assessments from 01/04/16 to 01/07/16 reflected the following:

a) Left circumferential shin-partial thickness, blister, [DIAGNOSES REDACTED], peeling and SCD blister

b) Right posterior heel-partial thickness, bruise or contusion due to trauma and deep tissue injury.

c) Coccyx-full thickness, shear.

d) There was no assessment of length, width, depth, exudate type, exudate amount and tissue type and stage as required by policy and procedure. There was no evidence the deep tissue injury of the right heel was assessed if the area was firm, boggy, tender, etc.

e) There was no evidence pictures were taken of the patient's identified skin conditions on admission or at discharge as required by policy and procedure.


3) Review of the General Nurse's Note dated 01/06/16 at 1306 revealed "...states that her left leg is hurting and rates it 6/10 and tolerable ...Left leg from calf to foot is wrapped with a gauze wrap as well as the right ankle, both are CDI [clean, dry and intact], (Named) told me that this was from her SCDs that she had on when in post surgery and that they are putting zinc ointment on it once a day and had it done last on night shift ...She placed zinc ointment on her pressure ulcer on her coccyx this AM ..."


4) There were no pictures available for review as confirmed in the facility's submitted document on 02/22/16.


D. Nutrition


1) The nutritional assessment was completed on 01/16/16. There was no evidence the Dietitian identified the patient had wounds which potentially impacted the patient's care. Under intervention it was written, "Alternative to menu offered. Pt has become fatigued with Nepro but would drink ensure ..." The Dietitian did not address how often the supplement was to be given.


2) Review of the intake and output records from 01/04/16 to 01/07/16 there was no evidence an oral nutritional supplement was given.


E. Review of the Plan of Care of the Integumentary system revealed the goal/outcome was not written in measurable terms. The goal was to improve. It was difficult to ascertain what interventions were to be used to improve the outcome for the skin alteration. The format was to list all of the problems first and then list all interventions. The interventions were not linked back to a problem.



5. Patient #1-Admission 12/22/16 to 01/04/16 (Rehabilitation Unit)


A. SCD


1) Review of the admission physician orders dated 12/21/15 revealed there was no order for the use of SCDs. Review of the narrative document sent by facility and received on 02/22/16 revealed it was confirmed there was no evidence of a physician's order for SCDs.


2) Review of the Mechanical VTE Prophylaxis assessment from 12/22/15 to 01/04/16 revealed the procedure was not wanted. There was no documented evidence why the treatment was not wanted. There was no evidence the nursing staff was aware of no order based on the fact documentation reflected they attempted to apply the SCDs and the patient refused. There was no evidence the physician or nursing staff had assessed whether the patient had contraindications to wearing the SCDs such as peripheral vascular disease, serious arterial insufficiency, ischemic vascular disease and heart failure.


B. Wound Care/Management


1) Review of the nursing comprehensive assessment dated [DATE] revealed the following integumentary assessment:

a) Bilateral heels had a "bruise or contusion due to trauma. Deep purple discoloration. ? [question] potential DTI [deep tissue injury]." There was no description as to the size, the feel of the discolored area i.e., boggy, firm, etc.

b) Left buttocks had bruise or contusion due to trauma. There was a very dark discoloration. It was questioned if it was a potential deep tissue injury. There was no description as to the size, the feel of the discolored area i.e., boggy, firm, etc.

c) Left hip had an incision. There was no description as to the size and the appearance of the incision.


2) Review of the General Nurse's Notes from 12/22/15 to 01/04/16 and focused Integumentary assessments from 12/22-25/15 revealed the bilateral heels had a deep tissue injury, bruise, contusion and abrasion. There was no assessment as to the size, tenderness present, or if the area was boggy, firm, etc. It could not be determined if the bilateral heels had improved, declined or remained stabilized.


3) Review of the General Nurse's Notes from 12/22/15 to 01/04/16 for the LLE revealed the nursing staff identified the LLE was red with weepy skin on 12/25/16 at 1920; there was no evidence how much of the LLE was red or the color of the weepy liquid. Then on 12/27/15 at 1920 it was assessed the LLE had exudate but there was no assessment of the color of the exudate present. On 12/24/15 at 0715, the nurse assessed there was a blister to the left lower posterior leg that was draining. There was no description of the size, exudate type and exudate amount. From 12/25/15 to 12/27/15, the nursing staff recorded the LLE continued to be red, warm, weepy and tender. Then on 12/31/15 at 1508 the LLE was assessed to have a tape blister measuring 4 cm x 3 cm. There was no evidence of the location of the blistered area on the LLE. There was no description of the blistered area to determine size, depth, exudate etc. There was no evidence the nursing staff assessed whether the tape used should have been substituted by another product as this was the second location identified as having a tape blister. The nursing staff assessed the LLE had abrasions on 01/01/16 at 0715. There was no evidence whether the abrasions were new; there was no evidence of the location and description of the abrasions; and there was no evidence to determine if the abrasions were the same as previously described as a blister. On 01/02/16 at 0730, the nursing staff assessed there was weeping to stasis looking ulcers to lower extremities that was worse on LLE. There was no evidence of how many ulcers to the LLE, where the ulcers were located on the LLE, and no descriptive assessment of the ulcers now located on the RLE (right lower extremity). There was no evidence of how the assessment related to previous assessment which was identified as blisters and weepy areas. There was no description of the ulcers as to the size, depth, exudate, etc. The level of decline or stabilization could not be determined due to the inconsistencies in identifying the location of the wounds and not assessing the size, depth, exudate type, exudate amount, and tissue type


4) Review of the General Nurse's Note from 12/22/15 to 01/04/16 revealed inconsistencies in the location of the wound located on the left buttocks. There were references to the bottom and coccyx but it could not be determined if the locations were all the same or if the wounds were new since the original assessment was the left buttocks. When nursing staff referenced the bottom and coccyx there was no descriptive assessment of the wounds to include the size, exudate, exudate amount, tissue type, stage if related to pressure and tissue type. It could not be determined if the wounds declined, were stabilized, or improved due to the inconsistencies in the assessments and no descriptions of the size, depth, exudate type, exudate amount and tissue type. For example:

a) On 12/26/15 at 0730, "Zinc applied to buttocks Stage II..." There was evidence of the size, depth, exudate color, which buttocks, location on the buttocks, etc. There was no evidence if Stage II was a new wound or if it was the same wound identified as a 3rd degree burn from tape on 12/23/15 at 0844 in the focused Integumentary assessment.

b) On 12/26/15 at 1651, "Zinc applied to bottom and tape blisters to left hip area." There was no evidence if the zinc to the bottom was the same as the buttocks noted at 0730.

c) On 12/27/15 at 0510, "Zinc applied to coccyx ..." There was no evidence if this was a new area if it coincided with one of the previous cited as the buttocks or bottom.

d) On 12/28/15 at 1529, "...Blister to left buttocks w [with]/zinc ..." There was no evidence one blister or more as previous documentation was plural.

e) On 01/02/16 at 0704, "...Decub [decubitus] left medial buttock dark eschar area 8-10 cm area." There was no evidence if this was a new identified area or if it related to the area previous identified as blisters due to tape. There was no evidence if this was the same area as noted on the left buttock/bottom/coccyx. Since there was no previous descriptions it could not be determined the level of decline.


5) Pictures

a) Review of the pictures dated 12/22/15 revealed there were a total of 9. The pictures had no identification of the location of each wound as required by procedure Wound Management: Surgical/Non-surgical or Wound Management: Pressure Ulcer Risk Assessment/Prevention/Management. Based on the comprehensive assessment there were only a total 4 of the wounds identified.

b) Review of the pictures dated 12/31/15 there were a total of 4 pictures. The pictures had no identification of the location of each wound as required by procedure Wound Management: Surgical/Non-surgical or Wound Management: Pressure Ulcer Risk Assessment/Prevention/Management.

c) There was no evidence pictures were taken at discharge on 01/04/16 back to acute care.


C. Nutrition

1) Review of the physician's order dated 12/23/15 at 1117 revealed a nutritional supplement of Ensure BID (any flavor).

2) Review of the Dietitian's assessment on 12/23/15 at 1130 revealed "Alternative to menu offered. Pt agreeable to drink Nepro BID."

3) There was no evidence the physician's order was clarified to determine if the nutritional supplement was to be Ensure or Nepro.

4) Review of the Intake and Output record from 12/23/15 to 01/04/16 revealed there was no evidence the nutritional supplement was recorded to assist the Dietitian in determining the patient's nutritional needs were met. Review of the narrative document sent by facility and received on 02/22/16 revealed it was confirmed there was no evidence the nutritional supplements were recorded.


D. Plan of Care


1) Review of Altered Nutrition revealed the goal was "Nutritional intake meets the metabolic requirements". There was no measurability to goal to identify what the patient had to consume nutritional to meet metabolic requirements. The intervention for a nutritional supplement did not include the frequency to administration


2) Review of Altered Skin Integrity revealed the goal was "Skin intact or integrity improved". The interventions had three sections identified as pressure ulcer present, surgical wound and non-surgical wound. Under pressure ulcer, it was written suspected DTI bilateral heels with interventions of initiate appropriate Pressure Ulcer Algorithm, Monitor for signs/symptoms of [DIAGNOSES REDACTED]. There was no evidence the patient had been assessed for a different product when the patient had more than one blister resulting from tape to change the plan of care to prevent further skin impairment from tape application.



6. Patient #1-Admission 12/16-22/15


A. Review of a physician's order dated 12/17/15 revealed "Sequential Compression Devices Continuous while in bed."


B. Review of a consultative note dated 12/17/15 revealed the physician had identified the patient's past medical history included congestive heart failure, atrial fibrillation, chronic renal failure, peripheral vascular disease, coronary artery disease and history of GI bleeding.


C. Review of the Mechanical VTE Prophylaxis assessment and Cardiac Assessment from 12/16-22/16 revealed SCDs were applied but, there was no evidence the skin was inspected and assessed every 8 hours. There was no evidence the patient was evaluated for potential contraindications for use such as peripheral vascular disease, coronary artery disease, congestive heart failure, etc. Review of the facility submitted documents on 02/22/16 revealed confirmation there was no evidence the SCDs were removed and the skin inspected every 8 hours.


D. Review of the Plan of Care of the Integumentary system revealed it was difficult to ascertain what interventions were to be used to improve the outcome for the skin alteration. The format was to list all of the problems first and then list all interventions. The interventions were not linked back to a problem.


7. Patient #2-Admission 01/21/16 (Current)


A. SCD


1) Review of the physician's order dated 01/21/16 at 1647 revealed "Sequential Compression Devices Continuous-While in bed."


2) Review of the computerized plan of care revealed VTE (venous thromoboembolism) Mechanical Prophylaxis (same as SCD) was identified as an intervention every shift.


3) Review of the computerized Mechanical VTE Prophylaxis assessment from 01/21-27/16 revealed the SCDs were applied bilaterally. There was no evidence the SCDs were removed and the skin inspected every 8 hours.


B. Wound Care/Management


1) Review of the Integumentary assessment dated [DATE] revealed a Stage II ulcer was identified on the sacrum and right buttock. There was no assessment of the ulcer size, exudate, exudate type and tissue type. From 01/25-27/16, the sacrum and right buttock was identified as having a suspected DTI. There was no evidence why the assessment changed from a Stage II ulcer to a suspected DTI.


2) Review of the Integumentary assessment from 01/25-27/16, there was no suspected DTI identified to the right sacrum, sacrum and left sacrum. There was no assessment to describe the size, color, the feel (boggy, firm) of the area, or if the area was tender.


3) Review of the Integumentary Assessment Form 01/25-26/16, the patient was assessed to have superficial excoriation to the groining area.


4) Review of the General Nurse's Note dated 01/21/16 at 2000 revealed "...Pt has multiple sores on buttocks, pictures taken..." There was no identification the location of the buttocks or if it was the left and right buttocks. There was no evidence of a description of the multiple sores on the buttocks.


5) Review of the pictures taken on 01/21/16 revealed there was no identification of the location of the multiple sites.


6) There was no evidence the PUSH Tool was used.


C. Weight


1) Review of the physician's order dated 01/21/16 at 1647 revealed to weigh daily.

2) Review of the Dietitian's nutritional follow-up dated 01/25/16 at 1351 revealed she recommended the patient's weight be rechecked.

3) Review of the recorded daily weights revealed there was no evidence the weight was rechecked as requested.


D. Nutrition

1) Review of the Dietitian's initial assessment dated [DATE] at 1043 revealed Vanilla boost was to be added to the meal trays.


2) Review of the Intake and Output from 01/22/16 to 01/27/16 revealed there was no evidence the percentage of the Vanilla boost was not recorded separately to assist the Dietitian in assuring