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.

MONUMENT HEALTH RAPID CITY HOSPITAL 353 FAIRMONT BLVD POST OFFICE BOX 6000 RAPID CITY, SD 57701 Feb. 6, 2014
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed to ensure:
*The nursing staff identified, assessed, and implemented interventions to prevent the development of pressure ulcers (PU) at the time of admission for two of five sampled patients (1 and 7) identified as high-risk for skin breakdown.
*The nursing staff initiated a referral to the registered dietitian (RD) to assess the nutritional status for one of five sampled patients (1) with PUs.
*The PU treatment information had been communicated to the receiving long term care provider for one of five sampled patients (1) upon discharge.
Findings include:

1. Review of patients 1's electronic medical record and nursing assessments revealed:
*He had been admitted on [DATE] and was discharged on [DATE].
*His diagnoses included:
-Ischemic (poor blood circulation) of the left (L) foot with an ulceration (breakdown of the skin) over the fifth toe.
-Multiple bilateral (both) arterial (blood vessel) occlusions (blockages) of the lower extremities (legs).
-End-stage renal (kidney) disease that required dialysis.
-Insulin dependent diabetes with retinopathy (diabetes had caused damage to the blood vessels of the eye causing light sensitivity) and neuropathy (nerve damage causing pain or numbness to the extremities [arms and legs]).
-Hypertension (high blood pressure).
-Hyperglycemia (high blood sugars) that indicated poor diabetic control.
-Confusion.
*On 1/3/14 the initial patient assessment in the emergency room (ER) was completed and a wound on the patient's L foot fifth toe was identified and documented. There was no documentation the patient had a PU on his L heel, right (R) heel, and two PUs on his sacral (buttock) area. There was no ER documentation of additional wounds, PUs, or skin breakdown.
*On 1/10/14 the nursing staff had placed an overlay mattress (filled with air) on the patient's bed to relieve pressure, because he had been bedfast (spending a lot of time in bed).
*On 1/22/14 the nursing staff had documented the use of foam boots to protect his feet from pressure.
*The RD had not been contacted to assess his nutritional status or to make suggestions for nutritional interventions for his PUs.

Interview on 2/6/14 at 2:35 p.m. with the receiving facility's director of nursing (E) regarding patient 1 revealed:
*He had been readmitted to their facility from the hospital on [DATE].
*When the patient left their facility on 1/3/14 there were no R and L heel PUs, and no sacral PUs.
*There was a full body assessment completed by the nursing staff upon his return to the facility from the hospital on [DATE].
*There were no written or verbal orders communicated from the hospital regarding his current pressure ulcers upon his re-admission to the long term care facility.
*There was a dressing to the sacral area. The heels were open to air.
*She had called the hospital about the PUs and inquired about the current treatment to those areas. The nurse she had spoken to was unsure about the current treatments that had been provided during his hospitalization .
*The heels were unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan ,gray, green, or brown] and /or eschar [tan, brown, or black]). The heels were black in color.
*The sacral area was a stage 3 PU (full thickness tissue loss, subcutaneous fat might have been visible but bone, tendon, or muscle are not exposed, slough might have been present but does not obscure the depth of tissue loss. Might have included undermining and tunneling [you may not be able to determine how deep the area was]).
*The hospital social worker had reported no skin issues to the long term care staff prior to his readmission to their facility on 1/28/14.

Refer to A395, finding 1, and A837, finding 1.

2. Review of patient 7's nursing assessments, history and physical, and progress notes revealed:
*He had been admitted on [DATE].
*He was currently a patient at the hospital on [DATE].
*His diagnosis included a left toe ulceration (open area) that had required an amputation (removal of the toe).
*A PU to his sacrum (upper buttock region) was noted on 1/25/14 by the nursing staff. The PU was described as red, well approximated (the same), and surrounding tissue was pink and warm.
*There were no measurements documented until two days later on 1/27/14 by the wound care team.

Review of the provider's May 2012 Skin Assessment: Prevention, Reassessment, and Documentation policy revealed:
*The policy provided a consistent approach to skin care management for patients with impaired or the potential for impaired skin integrity. Identify patients at risk for developing skin breakdown and/or pressure ulcers and institute a plan of care that included preventative measures, ongoing monitoring, and assessment of wounds, treatment, and documentation.
*Documentation for a complex wound would include:
-Wound measurements for the complex wound should have occurred when the wound was first identified, and then once a week. If the wound care team was not following the patient, the weekly measurements would occur on Wednesdays by the nursing staff. They should have measured the length, width, and depth of the wound.
*A nutritional screening would have been completed by the nursing staff upon admission. If nutrition risk factors were identified during the screening, a professional assessment by a dietitian would have been generated.

The provider's October 2011 Wound Care Protocol revealed:
*Document all findings.
*Inform the primary nurse and notify ordering physician of any significant changes in the wound status.

Refer to A395, finding 2.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed to ensure:
*The nursing staff identified, assessed, and implemented interventions to prevent the development of pressure ulcers (PU) at the time of admission for two of five sampled patients (1 and 7) identified as high-risk for skin breakdown.
*The nursing staff initiated a referral to the registered dietician (RD) to assess the nutritional status for one of five sampled patients (1) with PUs.
Findings include:

1. Review of patient 1's 1/3/14 emergency room (ER) record revealed:
*He had been admitted on [DATE].
*His nursing assessment included the following:
-He had calf (back leg) tenderness.
-His left lower leg had some swelling.
-He had a wound to his left foot fifth toe.
-His skin was intact with no evidence of trauma.
-His skin was warm and dry.
*There was no documentation that identified any PUs to the patient's heels or to his sacrum (buttock) area.
*On his admission to the emergency room (ER) pulses in his feet were obtained by a doppler (a machine that detected pulses when otherwise unable to obtain per palpation [feel] by the nurse or the doctor), and he had edema (swelling) in his left (L) foot.

Review of patient 1's 1/3/14 history and physical report revealed:
*Significant history for diabetes mellitus with retinopathy (diabetes had caused damage to the blood vessels of the eye causing light sensitivity) and neuropathy (nerve damage causing pain or numbness to the extremities [arms and legs]), and he was insulin dependent.
*End stage renal disease that required dialysis.
*Hypertension (high blood pressure).
*His L foot was cool to touch. He had a diagnosis of ischemia (poor blood circulation.)
*No palpable pulse was noted on the L foot.
*There was dark dusky areas of discoloration of the toes, and the entire L foot with a 1 centimeter (cm) ulcer (open area) noted on his lateral (outer) surface of the small toe.
*He had an ischemic L foot with ulceration over the fifth toe, possibly early gangrenous transformation (dead tissue). He had multiple areas of arterial vessel occlusion of the lower extremities (his circulation was severely impaired).
*Severe peripheral vascular disease (poor blood circulation).

Review of patient 1's nursing assessments from 1/3/14 through 1/28/14 revealed:
*The initial 1/3/14 nursing assessment identified a wound on the patient's L foot fifth toe.
*The initial 1/3/14 nursing assessment had not identified or documented any skin breakdown on his L and R heels or on his sacral (upper buttock) area.
*The patient's ability to sense skin stimulation (sensation of feeling to the skin) was moderately impaired.
*He was bedfast upon admission.
*He was incontinent (unable to control urine) at times.
*His food intake and hydration status were moderately less than normal intake.
*His cognitive (mental) status was described as confused at times.
*On 1/9/14, six days after his admission, nursing staff had documented a PU to his L and R heels, and he had two PUs to his sacral area.
-The PU on the L and R heels were described as red and dusky.
-The sacral area PU was described as red and dusky.
-There were no measurements of the PUs documented by the nursing staff upon initial identification.
*On 1/10/14, seven days after his admission, interventions were initiated to off-load (remove pressure by repositioning the patient) and an over-lay mattress (a mattress filled with air) had been placed on his hospital bed.

Review of the wound care team documentation for patient 1's PUs revealed:
*On 1/10/14 the left and right heels and the sacral areas were photographed with a wound measuring guide (ruler to show the size), but there were no written measurements found in the electronic medical record.
*On 1/16/14 the left sacrum was measured and described as the following:
-Pink and red in appearance.
-A debridement (the manual removal of dead tissue) had been performed to remove the dead tissue from the area.
-The area measured 9.1 centimeters (cm) by 5.9 cm.
*On 1/16/14 the medial sacrum was described and measured as the following:
- The area was hardened, pink, slough, and yellow.
-The wound measured 3.5 cm by 2.9 cm.
*On 1/16/14 the L heel was described and measured as the following:
-The area was brown, dry, eschar (black tissue) and unstageable.
-The wound measured 4.5 cm by 4.0 cm.
*On 1/16/14 the R heel was described and measured as the following:
-Dry and maroon in color. Suspected to have been a deep tissue injury.
-The wound measured 3.5 cm by 3.1 cm.
*On 1/23/14 the medial sacrum was described as hardened, red, and measured 3.5 cm by 2.9 cm and was classified as a stage 2 PU (partial thickness loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). The wound was debrided by the wound nurse. The L heel had eschar and was unstageable. The area measured 4.5 cm by 4.0 cm. The R heel had eschar and was blackened. The area measured 3.5 cm by 3.1 cm. Betadine had been applied to the heels.

Review of patient 1's Braden scale (assessment done to predict pressure ulcer risk for the patient) revealed:
*On 1/4/14 his initial Braden scale was fourteen (moderate risk to develop pressure ulcer).
*The following Braden assessment scores were documented during his hospitalization :
-On 1/4/14 it was 14, moderate risk.
-On 1/5/14 it was 15 (mild risk) for developing pressure ulcers.
-On 1/8/14 it was 14.
-On 1/11/14 it was 12 (high risk).
-On 1/13/14 it was 11 (high risk).
-On 1/14/14 it was 11.
-On 1/15/14 it was 12.
-On 1/16/14 and 1/17/14 it was 14.
-On 1/18/14 it was 14.
-On 1/19/14, 1/22/14, and 1/25/14 it was 15.
*There was no consistency in regards to the Braden scale assessments documented by the nursing staff.

Review of patient's 1's physician's progress notes from 1/4/13 through 1/27/14 revealed there was no documentation regarding the patient's PUs on his L and R heels or on his sacral area. The progress notes had no documentation of the development of the PUs or if the PUs were unavoidable due the patient's medical conditions.

Review of patient 1's 1/28/14 physician's discharge summary revealed:
*He was discharged on [DATE] to a long term care facility.
*He was debilitated and required maximum assistance. He had been able to ambulate with a walker prior to his admission to the hospital.
*The lower L extremity wound was described as a dry, necrotic scab on the patients fifth toe without any signs of inflammation (swelling) around it.
*There was no edema and pulses were intact. There was no documentation about his L and R heel PUs or his medial sacrum PUs.

Interview and review on 2/6/14 at 10:00 a.m. of patient 1's electronic medical record with the quality assurance director revealed:
*The patient had acquired the L heel, R heel, and the sacral PUs during his current hospital stay.
*The RN that had completed the initial nursing assessment on 1/3/14 should have identified, assessed, and documented a full description with measurements of any skin breakdown at the time of admission.
*The nursing staff had first documented the patient had PUs to both heels and his sacral area on 1/9/14, six days after the patient's hospital admission.
*The nursing staff were responsible for the documentation of patients PUs or skin breakdown upon the initial discovery of the PU. If the wound team was not involved in the treatment of the PUs, then the primary care nurse would have been responsible for the description and the measurement of the PU weekly on Wednesday.
*The wound care team documented wound description and measurements on Thursday of each week.
*The wound care team recommended treatment options for patients with PUs or skin breakdown to the physician.
*There was no ER documentation of additional wounds, PUs, or skin breakdown on admission on 1/3/14.
*There was no documentation the nursing staff had contacted the physician to request a nutritional assessment for the patient. A nutritional assessment by the RD was not found in the patients electronic medical record

Interview on 2/6/14 at 1:50 p.m. with registered nurse C regarding patients with PUs revealed:
*The communication between the wound care team and the primary care nursing staff had not occurred on a consistent basis.
*She would not have known when the wound nurse had visited a patient with a PU, because there was no communication between the wound care team and the primary care nurses.
*At times it was difficult to have determined what treatments the wound care team had implemented for the patient.
*There were no oral reports given between the wound care team and the nursing staff, but there was documentation in the electronic medical record.

Interview on 2/6/14 at 2:35 p.m. with the receiving facility's director of nursing (E) regarding patient 1 revealed:
*He had been readmitted to their facility from the hospital on [DATE].
*When the patient had left their facility on 1/3/14 there were no R and L heel PUs, and no sacral PUs.
*There was a full body assessment completed by the nursing staff upon his return to the facility from the hospital on [DATE].
*There were no written or verbal orders communicated from the hospital regarding his current pressure ulcers upon his re-admission to the long term care facility.
*There was a dressing to the sacral area. The heels were open to air.
*She had called the hospital about the PUs and inquired about the current treatment to those areas. The nurse she had spoken to was unsure about the current treatments that had been provided during his hospitalization .
*The heels were unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan ,gray, green, or brown] and/or eschar [tan, brown, or black]). The heels were black in color.
*The sacral area was a stage 3 PU (full thickness tissue loss, subcutaneous fat might have been visible but bone, tendon, or muscle are not exposed, slough might have been present but does not obscure the depth of tissue loss. Might have included undermining and tunneling [you may not be able to determine how deep the area was]).
*The hospital social worker had reported no skin issues to the long term care staff prior to his readmission to their facility on 1/28/14.

2. Review of patient 7's nursing assessments, history and physical, and progress notes revealed:
*He had been admitted on [DATE].
*He was currently a patient at the hospital on [DATE].
*His diagnosis included a left toe ulceration that required an amputation (removal of the toe).
*A pressure ulcer to his sacrum (upper buttock region) was noted on 1/25/14 by the nursing staff. The pressure ulcer was described as red, well approximated, and the surrounding tissue was pink and warm. There was no measurement of the pressure ulcer.
*There were no measurements documented until two days later on 1/27/14 by the wound care team. The following pressure ulcer measurements to the sacrum were documented:
-On 1/27/14 the area was 0.1 centimeters (cm) by 0.5 cm.
-On 1/30/14 the area was 0.8 cm by 0.5 cm with a depth of 0.1 cm.
-On 2/3/14 the area was 0.7 cm by 0.3 cm.
-On 2/6/14 the area was 0.7 cm by 0.3 cm.

3. Interview on 2/6/14 at 1:25 p.m. with wound care nurse D regarding the above concerns for patients 1 and 7 revealed:
*There should have been interventions implemented upon admission if that patient was at risk for developing pressure ulcers.
*The nursing staff should have documented the measurement of the pressure ulcer when the areas were first identified.
*The wound care team would have notified the physician after the initial assessment had been completed to inform him/her of the recommended treatment for the patient.
*The registered dietician would not have assessed the patients with pressure ulcers without a physician's order.

Interview on 2/6/14 at 1:50 p.m. with registered nurse C regarding patient 7 and all patients with known pressure ulcers revealed:
*The wound care team would have visited patient 7 on Thursdays. The wound care team had not communicated to the nursing staff the status of the pressure ulcers. The wound care nurse would have seen the patient but would not communicate those findings to the primary care nurses.
*There should have been a clear and concise procedure for all staff to follow to ensure the continuity of care.
*Pressure ulcers that were initially identified by nursing should have been measured and documented.

Review of the provider's May 2012 Skin Assessment: Prevention, Reassessment, and Documentation policy revealed:
*The policy provided a consistent approach to skin care management for patients with impaired or the potential for impaired skin integrity. Identify patients at risk for developing skin breakdown and/or pressure ulcers and institute a plan of care that included preventative measures, ongoing monitoring, and assessment of wounds, treatment, and documentation.
*Documentation for a complex wound would include:
-Wound measurements for the complex wound should have occurred when the wound was first identified, and then once a week. If the wound care team was not following the patient, the weekly measurements would occur on Wednesdays by the nursing staff. They should have measured the length, width, and depth of the wound.
*A nutritional screening would have been completed by the nursing staff upon admission. If nutrition risk factors were identified during the screening, a professional assessment by a dietitian would have been generated.

The provider's October 2011 Wound Care Protocol revealed:
*Document all findings.
*Inform the primary nurse and notify ordering physician of any significant changes in the wound status.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and policy review, the provider failed to ensure patients transferred to another long term care provider had their care and treatment communicated to the receiving provider for one of five sampled patients (1). Findings include:

1. Review of patient 1's nursing assessment, history and physical, wound team notes, discharge summary, progress notes, and transfer information revealed he had:
*Been admitted on [DATE].
*Been discharged to a skilled nursing facility on 1/28/14.
*Diagnoses that included PVD (peripheral vascular disease [poor circulation]), insulin dependent diabetes, ischemia (no blood circulation) to the left (L) foot, ESRD (end state renal disease), and was on dialysis.
*On 1/9/14 he had pressure ulcers documented to his L heel, right (R) heel, and two pressure ulcers on his sacral (buttocks) region.
*On 1/28/14 the documents that had been sent to the accepting facility after the discharge of patient 1 included:
-Discharge medication list.
-Discharge summary. The physician discharge summary had no documentation of the pressure ulcers noted to his L and R heels or the two pressure ulcers on the sacral region.

Interview on 2/6/14 at 1:25 p.m. with wound nurse D regarding patient 1's pressure ulcers revealed:
*The wound care team had not communicated any orders to the accepting facility.
*The nursing staff should have notified the wound care team of his discharge, and then the wound care team would have written orders prior to his transfer to another facility.

Interview on 2/6/14 at 1:50 p.m. with registered nurse C regarding patient 1 and other patients with skin issues revealed:
*The wound care team would visit patients with pressure ulcers during the week and decide how often the patient would have been seen.
*The wound care team had not communicated with the nursing staff caring for those patients with pressure ulcers.
*There should have been clear and precise procedures for the care of patients with pressure ulcers.

Interview on 2/6/14 at 2:25 p.m. with the department director for resource management B and discharge planner A regarding patient 1 revealed:
*The discharge planner would fax the current physician's orders to the accepting facility prior to the patient's discharge.
*The wound care team would write orders for the accepting facility if the patient had a current pressure ulcer.
*The progress notes would have included who communicated the update about the patient to the accepting facility.

Interview on 2/6/14 at 2:35 p.m. with the receiving facility's director of nursing (E) regarding patient 1 revealed:
*He had been readmitted to their facility from the hospital on [DATE].
*When the patient had left their facility on 1/3/14 there were no R and L heel PUs, and no sacral PUs.
*There was a full body assessment completed by the nursing staff upon his return to the facility from the hospital on [DATE].
*There were no written or verbal orders communicated from the hospital regarding his current pressure ulcers upon his re-admission to the long term care facility.
*There was a dressing to the sacral area. The heels were open to air.
*She had called the hospital about the PUs and inquired about the current treatment to those areas. The nurse she had spoken to was unsure about the current treatments that had been provided during his hospitalization .
*The heels were unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown] and/or eschar [tan, brown, or black]). The heels were black in color.
*The sacral area was a stage 3 PU (full thickness tissue loss, subcutaneous fat might have been visible but bone, tendon, or muscle are not exposed, slough might have been present but does not obscure the depth of tissue loss. Might have included undermining and tunneling [you may not be able to determine how deep the area was]).
*The hospital social worker had reported no skin issues to the long term care staff prior to his readmission to their facility on 1/28/14.

Review of the provider's revised October 2013 Discharge Planning Process policy revealed the registered nurse (RN)/care manager and social worker/discharge planners would coordinate discharge plans that included a skilled nursing facility.

Review of a revised 1/24/11 copying charts for patient's transfers to nursing homes list provided to this surveyor revealed documents that should have been sent with the patient included:
*Physician's order for transfer.
*Nursing facilities routine orders.
*Medication orders.
*Patient transfer form.
*Discharge summary.
*History and physical.
*Consultation reports.
*Medical imaging reports.
*Cumulative laboratory reports.
*Wound care order.
*Physician progress notes.
*Face sheet.