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.

CLEVELAND CLINIC MARTIN NORTH HOSPITAL 200 SE HOSPITAL AVE STUART, FL 34995 March 4, 2014
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical and administrative record review and staff interview, the nurses failed to perform timely and complete assessments on 2 of 10 patients (Patient # 2 and 3) identified at risk for the development of pressure ulcers as evidenced by the Registered Nurses' failure to provide documentation of performing a visual skin assessment of the patients each shift. The staff failure to perform the necessary reassessment prevented early detection and treatment, and the patients subsequently developed pressure ulcers.

The findings include:

Review of the facility's policy titled Pressure Ulcer Prevention Protocol documented, "The Braden Pressure Ulcer Risk Assessment tool will be used to identify those patients who are at risk for threatened skin integrity and contributing factors. Patients will be assessed for pressure ulcer risk upon admission and every shift. Assessment will be documented in the Electronic Medical Record (EMR). Visually assess patient's general skin condition from head to toe every shift and document if pressure ulcer present in EMR. For Risk score 18 or less, implement the prevention protocols as outlined. Document implemented interventions in EMR".

Review of the facility's policy and procedure titled Pressure Ulcer Risk Treatment Protocol documented, "Determine stage of pressure ulcer. Document in EMR (Electronic Medical Record). Each individual area must be documented separately and will include location, size, wound bed tissue seen, drainage type and amount, condition of periwound skin, extent of the tissue damage by staging including unstageable. Follow standing protocols for pressure ulcer treatment."

The facility's Pressure Ulcer Protocol and Care Pathway documented for Unstageable - "A Pressure ulcer , wound bed is covered with slough and/or black eschar (necrotic tissue). Suspected deep tissue Injury - purple or maroon localized area of discolored intact skin or blood blister. Stage 1- Intact skin with non-blanchable redness, goal cover and protect area from pressure."

The facility failed to provide evidence of adherence to their policy and procedure for the following patients:

1) Review of the clinical record for Patient # 3 discloses that the patient was admitted to the facility on [DATE]. The 2/16/2014 at 1:45 AM initial assessment identified that the patient had a skin tear to her elbow, head laceration and an incision on her left hip. There are no further skin issues identified. The patient's Braden Pressure Ulcer Risk Assessment score was 13. A score of 13-14 is a Moderate Risk. On 2/18/2014 at 8:00 PM, the nurse documented that the patient's coccyx was red. There is no further information provided regarding the reddened area identified on 2/18/2014. Furthermore, closer review of the clinical record failed to provide corroborative evidence that further shift assessments were completed on the patient until 1 1/2 days later on 2/20/2014 at 6:30 AM when the nurse documented that the patient had a bruise in her coccyx area. Again there is no further assessment information documented until 3 days later on 2/23/2014 at 2:08 PM, when the nurse noted that the patient's buttocks is "reddened." As previously noted, there are no further details regarding the identified area. Then on 2/24/2014 at 6:31 PM, the nurse noted the patient had a "large ecchymotic area to her left buttocks, abrasion times two to buttocks". Documented on 2/24/2014 is a picture that identified the area measured as 5 cm by 9 , no undermining, tunneling or drainage.
The Wound Care Nurse assessed the patient's wound on 2/25/2014 at 11:33 AM and she identified that the patient has an Unstageable 6 x 8 x 0.2 cm wound with 20% red/pink, 80% black. Again pictures were taken which confirms the documented assessment.

An observation of the patient's wound was conducted on 3/4/2014 at 2:39 PM with the Physician and the Clinical Coordinator of Wound Care. The physician stated that he had prescribed for the patient to receive the Santyl dressing, which will debride the wound. The wound is now classified as a Stage III.

An interview was conducted on 3/3/2014 in the afternoon and 3/4/2014 in the morning with the Clinical Coordinator, who confirmed that there was no additional documentation confirming the nursing staff performed the skin assessments each shift.


2) Review of the clinical record for Patient # 2 discloses the patient was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]. The initial assessment did not identify that the patient had skin issues on admission.
The Wound Care Nurse evaluated the patient on 1/16/2014 and documented that the patient had a history of impacting wound and objectively assessed the patient to identify that the patient had "multiple small dry callous areas to bilateral feed. No drainage noted." The patient continues to not have open pressure areas identified. However, on 1/20/2014 the nurse identified a 1 cm x 1 cm x 0.1 cm area on the patient's left lateral great toe. No stage identified. On 2/10/2014 a Stage II pressure ulcer was identified on the patient's left hip measuring 3 cm x 1 cm. Review of the nursing shift assessment did not provide corroborative evidence that the nurses consistently performed the visual body assessments of the patient each shift prior to the development of the pressure areas and subsequently after the wounds developed.

An interview was conducted on 3/3/2014 in the afternoon with the Clinical Manager who confirmed she was unable to locate documentation that the nurses performed the skin assessments each shift.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, clinical and administrative record review and staff interview, the nurses failed to implement and individualize care plans to meet the needs of patients determined to be at risk for the development of pressure ulcers. The patients subsequently developed worsening pressure ulcers. This affected 2 of 10 sampled patients (Patient # 2, and Patient # 3).

The findings include:

1) Review of the clinical record for Patient # 3 discloses that the patient was admitted to the facility on [DATE]. The initial 2/16/14 skin assessment disclosed that the patient is a moderate risk for the development of pressure ulcers and did not have pressure ulcers at this time. Subsequent assessments identified that the patient had identified skin issues (please refer to A392 for specifics) and the patient eventually developed an unstageable wound on her coccyx on 2/24/2014.

An initial care plan dated 2/16/2014 identified an issue of Potential for Compromised Skin Integrity with the following interventions: Skin integrity is maintained or improved; Turn patient (as needed); relieve pressure to bony prominences, Provide measures to decrease pressure to skin such as specialty mattresses, egg crate mattresses and beds, elbow and heel protectors; Avoid Shearing (as needed), Keep skin clean and dry, alternate a full bath with partial bath, encourage use of lotion/moisturizers, monitor patient's hygiene practices, Collaborate with Wound, Ostomy nurse (as needed). There is no evidence the facility updated the patient's care plan for interventions as necessary to prevent the further development of pressure ulcers.

An interview was conducted on 3/3/2014 in the afternoon and 3/4/2014 in the morning with the Clinical Manager who confirmed the facility nurses failed to provide evidence that the patient's skin was assessed each shift. She further stated that a general care plan is initiated on admission and subsequent updates are from physician order or the nurse can make recommendations, which would be noted in the EMR.

An observation of the patient on 3/4/2014 at 2:15 PM noted the patient out of bed in the chair. After further investigation it was revealed that the patient was placed in the chair between 9-10 AM by therapy and has remained in the chair at the time of the observation, 5-6 hours later.

An interview was conducted on 3/4/2014 at 2:15 PM with the daughter who confirmed that her mother had been up in the chair since before 10:00 AM because she was already in the chair when she arrived this morning. She stated she has been in the room and confirmed that her mother's position had not been changed since being placed in the chair. She stated that her mother has declined since admission and was ambulatory with a walker and independent without skin issues prior to this hospitalization for a fractured hip. She stated she was unaware of her mother having skin issues until 2/27/2014, when she was informed of the advanced nature of the wound and that treatment option was a possible referral to Hospice because a surgical intervention is not an option due to her mother's age and health issues.

An observation of the patient's wound was conducted on 3/4/2014 at 2:39 PM with the physician, Nurse Practitioner, Registered Nurse and Certified Nursing Assistant. The patient's wound was noted to be an extensive size wound with noted eschar and slough tissues. The physician noted that the patient's wound was now a Stage III. It should also be noted that it took extensive assistance from the nurse and the aide and a walker in front of the patient for her to stand up. The physician also assisted with holding the patient's right arm.

An interview was conducted on 3/4/2014 after the above observation with the Wound Care Clinical Coordinator who stated that the patient's wound initiated with deep trauma injury, and the patient needs frequent changes in position with turning. The surveyor questioned the wound care nurse (WCN) regarding the plan of care for the patient in the chair. She stated that the patient is sitting on a specialty pad (Redistributing foam). The patient should be encouraged to change position each hour. The surveyor then questioned the WCN regarding specifics for this patient because she is unable to move herself at this time, so the staff would have to move the resident, by standing her up, shift her position in the chair, etc.

An interview was conducted on 3/4/2014 at 2:30 PM with the Certified Nursing Assistant (CNA) who confirmed she had not repositioned the patient in the chair. She stated the family has been in the room visiting, and she did not want to disturb. The aide was questioned regarding offering to change the patient's position. She admitted that she had not approached the family concerning repositioning the patient. She stated she is aware that the patient has a wound on her buttocks, and she was going to transfer her back to bed and give her care then. The aide was also questioned about the care needs of the patient and the importance of position changes. She confirmed she had not changed the patient's position or stood the patient up to provide pressure relief on her buttock.

An interview was conducted with the Registered Nurse on 3/4/2014 at 3:00 PM. The nurse confirmed that physical therapy placed the patient in the chair about 9:00 AM, and though she has administered medications to the patient, she denied assisting the aide at any point today to change the patient's position.


2) Review of the clinical record for Patient # 2 discloses the patient was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]
The Wound Care Nurse evaluated the patient on 1/16/2014 and documented that the patient had a history of impacting wound and objectively assessed the patient to identify that the patient had "multiple small dry callous areas to bilateral feet. No drainage noted." The Wound Care Nurse (WCN) also documented that the patient is contracted and constantly moving. Skin care recommended. Wash bilateral feet with warm water and soap. Apply moisturizing lotion to feet and lower extremities. Continue offloading.
On 1/20/2014 the nurse identified that the patient had developed a 1 cm x 1 cm x 0.1 cm area on his left lateral great toe. No stage identified. A subsequent 2/23/2014 assessment documented that the patient's left lateral toe wound is 1 x 1.5 Stage II wound. The wound care is Santyl ointment after cleansing with Normal Saline and apply foam dressing.
On 2/10/2014 a Stage II pressure ulcer was identified on the patient's left hip measuring 3 cm x 1 cm.
Furthermore on 2/13/2014, the WCN again assessed the patient and noted that the patient had a Stage II pressure ulcer on his left hip measuring 3 cm x 0.4 cm x 0.1 cm and recommended cover with Duoderm every 4-5 day as needed. She further documented her recommendation plan to again wash the bilateral feet as previously noted, moisturizer, continue off loading and "Turn every hour and assure lower extremities are offloaded." Subsequently a 2/27/2014 Left hip assessment identified that the patient has a 3.5 cm x 1.5. Continue wound care with Duoderm after cleansing with Normal Saline.

Review of the facility's documentation for implementation of the recommendations revealed the facility staff turned the patient every 2-3 hours and did not follow the hourly recommendation by the wound care nurse.

An interview was conducted on 3/3/2014 in the afternoon with the Registered Nurse regarding Patient #2 and the nursing recommendations. A comment was made that the wound care nurse would have to be realistic in recommending the hourly turning. The nurse confirmed that the nurses acknowledged the physician order for the Duoderm, but the nursing recommendation for hourly turning was not acknowledged. She further confirmed the nurses do not need a physician order for turning, this can be a nursing recommendation. The care plan is initiated and the care plan at the time is generalized if specifics are needed then refer to the physician orders or nursing recommendations.

An interview was conducted on 3/4/2014 at approximately 3:00 PM with the Wound Care Clinical Coordinator who stated that when the Wound Care Nurses make recommendations for skin care or turning and positioning, they expect those recommendations to be carried out. The surveyor then reviewed with her the recommendation for Patient # 2 to have hourly turning and repositioning and offloading. She again stated that when the recommendation is made it is expected to be carried out based of the individual needs of the patient.