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.

KENDALL REGIONAL MEDICAL CENTER 11750 BIRD RD MIAMI, FL 33175 March 25, 2014
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure that the assessment of the pressure ulcer and care for each patient was conducted in 2 out 3 sampled patients(SP) (SP#10 and SP #12) with pressure ulcers of 13 Sampled Patients.

Findings include:
(1). Clinical record review of SP#10 conducted on 3/25/2014 revealed an admission date of [DATE] due to end-stage lung cancer. Review of the Wound Assessment/Reassessment Form on 3/4/2014 showed that the buttocks/sacrum areas were reddened but no broken skin. On 3/7/2014, the Wound Assessment/Reassessment Form showed that there was a pressure ulcer that was a Stage II and Unstageable. There was no wound measurements documented, or location on this date.
On 3/12/2014, the Wound Assessment/Reassessment Form showed that the pressure ulcer to the gluteal as a Stage II with slough/fibrin noted but there were no wound measurements documented on this date.
On 3/19/2014, the Wound Assessment/Reassessment Form showed that the pressure ulcer remained a Stage II to the gluteal with slough/fibrin noted, with maceration and [DIAGNOSES REDACTED] but there were no wound measurements documented on this date.
On 3/21/2014, the Wound assessment/Reassessment Form showed that the pressure ulcer to the sacrum as a Stage II with epithelialization and pink in appearance but there were no wound measurements documented on this date.
On 3/24/2014, the Wound Assessment/Reassessment Form showed that the Stage II pressure ulcer to the sacrum is resolving and no measurements. The Wound Care Response to Referral has the pressure ulcer as 3x4 cm (three by four centimeters) in measurements.
There was lack of documentation of the pressure ulcer measurements on the shift assessments record and on the Wound Assessment/Reassessment Form.
The Wound Care Nurse (WCN) stated on 3/25/2014 at 4:05 p.m. in the presence of the Director of Risk Management (Dir. of RM) the wound measurements must be charted, the tools are always available for the nurses to use to be able to measure the wounds. The Wound Care Nurse checked to see if there were any documentation of the wound measurements in the shift assessments and the Wound Care Nurse stated at 4:25 p.m. I didn't see in the shift assessments that the measurements were done either. These findings were confirmed by the Wound Care Nurse and the Director of Risk Management at 4:25 p.m. that there is no documentation of the wound measurements.


(2). Clinical record review of SP#12 conducted on 3/25/2014 revealed an admission date of [DATE] due to Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and bronchitis. The Adult Admission Assessment on 1/10/2014 showed that the patient's skin was intact. On 2/5/2014, it was documented in the Wound Care Center Response that the patient developed a Stage II pressure ulcer at the coccyx area. The Wound Assessment/Reassessment Form dated 2/5/2014 showed that wound measurements were done which has documented a stage II sacrum pressure ulcer at 3cm in length x 1cm in width.
The above findings were confirmed with the Wound Care Nurse and the Director of Risk Management on 3/25/2014 at 4:05 p.m. that the facility failed to ensure that the skin integrity of the patients was maintained intact.