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.

CHI ST LUKES HEALTH MEMORIAL LUFKIN 1201 WEST FRANK STREET LUFKIN, TX 75901 Feb. 26, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, and interview the facility failed to:

A. include the family/patient (pt) in the care planning and patient /family education for 1 of 1 patient identified.

Refer to Tag A 130


B.

Refer to Tag A 144
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on record review and interview, the facility failed to include the family/patient (pt) in the care planning and patient /family education for 1 of 1 patient identified.

On 2/26/2014, at 1:00 PM, in an office, the medical record (MR) for patient (pt) #1 was reviewed and revealed the following: The admitting physician documented in the History and Physical (H&P) the following: "There are no family members to discuss the patients condition".

Further review of the MR revealed that pt #1 was admitted from a local long term care (LTC) facility on 11/27/2013. He became acutely ill while at the LTC facility and was transported via ambulance to the emergency department (ED) of the hospital. After admission to the hospital, the family (daughter) was contacted by phone for verbal permission for placement of a percutaneous gastric feeding tube. Both nursing and physician documentation indicated pt #1 suffered from dementia and was unable to communicate his needs to the staff.

Review of the Social Workers documentation noted the daughter indicated her preference for LTC facilities to receive her father upon discharge.

The family was receptive by phone for notification of condition changed, education and requests related the pt #1 medical condition.

Review of the MR revealed that the nursing staff documented no attempt to communicate with the family related to the patient's deteriorating condition. The documentation of participation for care planning reflected no participation by the patient or his family.

Upon discharge, the family was not made aware of pt #1's skin condition, which included worsening of the original pressure wounds to pt #1's sacrum and heel, plus the development of new pressures wounds to the mid back, bilateral hips, multiple ischimic wounds to his bilateral feet and bruising. There was a total of 22 pressure wounds at discharge.

Patient #1's weight upon admission 11/29/13 was documented to be 267 lbs.. Upon discharge on 01/07/14, his weight was documented to be 192.2 lbs, a weight loss of 74.8 lbs. There was no documentation that the nursing staff notified the family about the weight loss of pt #1 during his hospital stay.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**





Based on observation, interview and document review, the Registered Nurses (RN) failed to consistently document accurate and descriptive skin assessments, failed to adequately provide nutritional support to pt #1, failed to maintain accurate weight records, failed to notify the physician and Registered Dietician inorder to meet the nutritional need of patient #1. These failures contributed to the development of additional skin breakdown, severe weight loss (74.8 lbs.), and continued aspiration.

On 2/26/2013, at 1:00 PM, the medical record for patient (pt) #1 was reviewed and revealed the following:

Pt #1 was a[AGE] years old patient, admitted on [DATE] from a local long term care facility.

The chief complaint for admission was vomiting of coffle-grounds emesis and shortness of breath (SOB). He was admitted through the hospitals Emergency Department with a diagnosis of [DIAGNOSES REDACTED]

Pt #1's past medical history included cardiovascular accident (CVA), coronary artery disease (CAD), hypertension (HTN), gastrointestinal (GI) bleed, congestive heart failure (CHF), renal failure, chronic obstructive pulmonary disease (COPD), dementia.

His admission weight (wt.) was 267 pounds (lbs). He was disoriented/demented with decreased range of motion in both upper and lower extremities (early contractures). Also noted by the admitting physician was "There are no family members to discuss the patient's condition".

The long term care facility discharged pt #1 to the acute hospital with documentation of two (2) unstaged wounds, (sacrum and left heel)

Further review of pt #1 MR revealed that a swallowing study was conducted by the licensed speech language pathologist on 12/4/2013, and revealed the following: "The patient demonstrated a severe sensory/motor oral dysphasia. Recommendations: 1) nothing by mouth, 2) Alternate means of nutrition and medication and 3) Speech therapy to address deficits." The RD recommended Jevity per PEG tube at 55 Milliliters if tolerated by pt #1. At 55 ml per hour pt #1"s nutritional needs would be met.

On 12/6/2013, pt #1 had placement of a percutaneous gastric feeding tube (PEG) conducted by staff #19. The documented plan was placement of a PEG tube for dysphasia related to multi-infarct dementia, history of multi-infarct dementia and urinary tract infection.

On 2/27/2014, at 2:00 PM, in the office, an interview with staff #9 revealed that the Registered Dietician submitted the request for a wound consult following the swallowing study and placement of the PEG tube.

Staff #20 conducted a wound consult and dictated the following: "No popliteal pulses were palpable in the left leg. There were no ulcers in the lower legs or right foot. An unstageable pressure ulcer of the left heel approximately 2 cm (centimeters) in diameter. An Unstageable sacral pressure ulcer, relatively small at this time, approximately 3 x 4 cm in dimensions". Staff #20 failed to order specific pressure relief mechanism for pt #1.

Review of MR for Pt #1's initial skin assessment revealed two (2) photographs dated 11/30/2013 identifying the sacral area and left heel. This was confirmed by staff #4 and #6.

Review of the MR document titled "Pressure Ulcer Prevention Program (PUPP) Standardized Form to Support Admission Documentation" indicated that the Admission RN, staff #21, identified the location of the pressure ulcers as, #1 "foot" and #2 "Coccyx". RN #21 failed to complete the form and failed to document staging of the wounds, size (length, width and depth), undermining or tracking, exudate (drainage), peri-wound observations. This form, dated of 11/29/2013 and timed 2030 (military time), documented only the number of pressure wounds as "2". This was also confirmed by staff #5.

Nursing documentation revealed these two wounds from 11/7/2013 until the day of discharge on 1/7/2014. However, nursing documentation indicated other areas of skin break down which were not assessed consistently and were not resolved prior to discharge. Examples of nursing documentation for these other areas of skin break down were as follows:

On 12/10/2013, at 2345, staff nurse #22 documented "water blister, arm, upper Right anterior. Heel left pressure ulcer, Sacral pressure ulcer stage II". This wound was not re-assessed and was not resolved based on nursing documentation.

On 12/13/2013, at 1002, staff nurse #27 documented "red rash" and "left heel pressure ulcer and right hip pressure ulcer stage III". This was the first indication of a hip wound. This wound was not assessed again and was not resolved based on nursing documentation. At 1935, staff #23 documented "Patient has red splotchy rash over arms. abdomen, and upper legs, and discoloration to lower legs as well as generalized bruising over arms, left heel pressure ulcer and sacral pressure ulcer stage III". There was no documentation to explain the generalized bruising and no resolution documented in the nurses documentation.

On 12/14/2013, at 1930, staff #28 documented a Braden score of 15/23. A score of 15 indicates moderate need for pressure relief and risk for skin break down. Staff #28 failed to document assessment of pt #1 rash and documented "no skin lesions".

On 12/15/2013, at 0723, staff #27 documented "Redness, sores, ulcerations. Rash all over body, which is improving. Blisters to upper left back. Pressure ulcer to left and right heel, stage III pressure ulcer to sacral (sic)". These wounds were not resolved based on documentation. At 1945, staff RN #25 documented "Redness, bruising, sores, ulceration, Rash to body which has greatly improved. [DIAGNOSES REDACTED] to upper left arm and blisters to upper left back. Pressure ulcer to left and right heel and pressure ulcer stage III to sacral (sic)." Both nurses documented the red skin rash but failed to assess the sores, ulcerations and blister. Documentation simply established the fact that the sores, ulcerations and blisters were present.

On 12/16/2013, at 0830, staff RN #29 documented "ulcerations, unable to stage on bilateral heals and coccyx, sacrum and buttocks". Nursing documentation revealed the presence of two wounds (Coccyx and foot) on admission and there were 5 wounds (bilateral heels, coccyx, sacrum and buttocks) identified based on the documentation.

On 12/19/2013, at 1900, staff nurse #31 documented "skin bruises, ulcerations stage II to coccyx and unstageable area to right heel, stage II wound to left heel". No other skin assessment was documented and no other previously documented skin irritation was resolved.

On 12/20/2013, at 0745, staff RN #33 documented "skin bruises, ulcerations, left heel pressure ulcer stage II, right heel pressure ulcer, sacral pressure ulcers stage III". At 2100 Staff #34 documented "skin color normal, signs and symptoms, none. No lesions noted". Staff #34 failed to assess pt #1 skin condition.

On 12/23/2013, at 0800, Staff #22 documented skin color normal for patient, ulcerations left and right heel pressure ulcers, right hip pressure ulcer". At 1946, staff RN #36 documented skin warm, intact, moist color normal for patient. Encourage oral fluids (patient was NPO, PEG Tube in place). Sacral pressure ulcer stage III". Both nurses failed to perform a thorough, and complete skin assessment with description of the findings.

On 12/24/2013, at 0828, staff RN #33 documented skin color normal for patient, ulcerations, encourage oral fluids (patient was NPO-PEG Tube in place). Left and right heel pressure ulcers, sacral pressure ulcer stage III". Staff #33 failed to perform a thorough, and complete skin assessment with description of the findings.

On 12/26/2013, at 1930, Staff RN #37 documented skin warm, dry skin color normal for patient, turgor loose, moist, ulcerations. Heel pressure sore is black in color. Left and right heels stage II pressure ulcers, sacral pressure ulcer stage IV". Nursing documentation revealed inconsistency in staging and describing pt #1 wounds.

On 12/27/2013, at 0755, staff RN #38 documented in the Braden scale, "Nutrition is excellent. (The PEG tube formula, Jevity, was not tolerated at the Registered Dietician's suggested rate of 55 millimeters (ml) per hour. Beginning the third day after the Jevity was started it was reduced by nursing staff to 25 ml. This rate does not meet the nutritional needs of pt #1) skin warm, dry, normal for patient, stage 3 to coccyx...No lesions noted.". No indication in the medical record that the RD or the MD was notified.

On 12/28/2012, at 0755, staff RN#38 documented "Skin dry, warm normal for patient fragile redness unstageable decubitus (sic) to coccyx...no lesions noted". Staff failed to perform a thoroughto evaluation of pt #1 skin condition.

On 12/29/2013, at 0800, staff RN #38 documented "Skin break down to right thigh pink, wounds to both heels...unstageable decubitus(sic) to buttock". The skin breakdown to right thigh was not asessed again and not resolved based on nursing documentation.

On 12/30/2013, at 0714, staff nurse #35 documented "Skin warm and dry, normal for patient, left and right heel stage II pressure ulcer, sacral pressure ulcer stage III". At 1920, staff RN #34 documented "skin warm, dry, normal; for patient turgor normal right and left heel wound and wound lower spine". The wound to the lower spine was not assessed again, nor resolved based on the nurses notes.

On 1/1/2014, there was no nursing assessment of pt #1 skin breakdown documented in the MR for the first shift. At 1930, staff #34 documented left and right heel wound and sacral wound". No other skin assessment was documented by the nurse.

On 1/2/2014, staff nurse #22 documented "discoloration noted to last two toes right foot, left and right heel pressure ulcer stage II sacral pressure ulcer stage III. Also pt with several stage 3 black wounds on bilateral feet also with abrasion of left lower inner leg dressing changed as ordered". This was the first and only time wounds to pt #1's bilateral feet, right toes, and lower inner leg were documented. All areas were documented as covered with black eschar by the long term care facility.

On 1/3/2014, staff nurse #35 documented "left and right heel pressure ulcers stage II and sacral pressure ulcer stage III". At 2000, staff RN #39 documented the Braden scale and nothing further. Staff #39 documented "No lesions noted". Both nurses failed to perform a complete, accurate and descriptive skin assessment.

On 1/4/2014, at 0729, staff nurse #35 documented "right foot pressure ulcer, left and right heel pressure ulcer stage II, Right anterior thigh pressure ulcer stage II, sacral pressure ulcer stage III". At 2000, staff #39 documented the Braden scale and no further skin assessment was recorded. Staff #39 again failed to perform a thorough complete skin assessment.

On 1/5/2014, at 0714, staff #35 documented "right foot pressure ulcer blisters, left and right heel pressure ulcer stage II, Right hip pressure stage II and sacral pressure ulcers stage III". At 2020, Staff RN #39 documented the Braden scale only. No further assessment of pt #1 skin was recorded.

On 1/6/2014, at 0800, staff RN #38 documented the Braden scale. Stage 4 to coccyx, stage 2 to both heels, dressing changed by night nurse". No second shift skin assessment was documented.

On 1/7/ , at 0730, staff #38 documented the Braden scale and "Multiple abrasions all over body. Stage 3 to coccyx... both heels stage 2". At 1800 staff #38 documented Santyl dressing to coccyx...painted both heels with betadine...". Both nurses failed to perform a thorough, accurate and complete assesment of pt #1 skin condition prior to discharge.

A review of the discharge instructions read as follows: Instructions #2: Wound/incision care group note: Santyl dressing to coccyx wet to dry daily and paint both heels with betadine solution daily cover with Kerlix. The discharge instructions failed to describe or instruct the care of the multiple other areas of skin break down (mid back, multiple foot/toe wounds, lower leg, hips)

On 2/27/2014 facility policies were reviewed and revealed the following:

Patient Care Services Guidelines: Titled "Interdisciplinary Documentation/Patient focused: Item II Patient EMR: A. Initial assessment must be performed by a Registered Nurse. Evaluations are performed every shift and whenever a change of condition is noted by a licensed nurse....Braden scale for skin assessment risk should be filled out completely each 12 hour shift".

Patient Care Services Guidelines: Titled "Photographic Documentation; Item V-Photos will be taken of: A.) Skin tears, significant cuts or bruising, ulcers of any stage 1-6 or areas that are suspected ulcers. Photographs will be taken upon admission and not taken again unless the physician orders it".

On 2/26/2014, in the office the following facility policy Guidelines were reviewed:

Patient Care Services Guidelines: Titled "Prevention of Alteration in Skin Integrity revised October 2013:

Item "B" Request pressure relief device (i.e. overlay, Clinitron) use heel and elbow protectors as needed. If patient requires specialty mattress on bed and can be up in chair then chair needs support cushion.

Item "R" Education of patient, family or significant other and document in teaching section of Electronic Medical Record (EMR)".

After review of the facility policies it was determined that the facility had no policy instructing the nursing staff concerning accurate, descriptive documentation of skin break down or actual pressure wounds..

Pt #1 was discharged from the acute care facility and admitted to a long term care (LTC) facility on 1/7/2014.

On 2/27/2014, at 4:15 PM, in the conference room of the LTC facility, pt #1's admission MR was reviewed.

Admission documentation dated 1/7/2014 recorded pt #1's admission weight was 192.2 pounds (a 74.8 pound weight loss from the 11/29/2013 hospital admission weight of 267 pounds).

Also the LTC facility documented twenty two (22) areas of skin break down. They are as follows:

1. Right mid back 2 x 1.5 Centimeter (cm) unstageable with slough.

2. Sacral area 11.5 x 6.5 cm unstageable, black/brown eschar to wound bed with slough, 1 cm undermining, slight odor.

3. Right trochanter 7.5 x 4.7 cm purple, deep tissue injury.

4. Right trochanter 4 x 4 cm, covered with black/brown eschar to wound bed, peri wound area red.

5. Right lateral foot (cuboid) 1.5 x 0.8 cm black eschar to wound.

6. Right 5th metaphylangel head (MP), 3.3 x 2 cm black eschar covering wound bed.

7. Right great toe medial aspect 1 x 1 cm Red

8. Right MP head 2 x 1.7 cm deep tissue injury

9. Right medial foot 1.7 0.7 cm purple, deep tissue injury

10. Right lateral heel 2.5 x 1.5 cm black eschar wound bed

11. Right medial heel 5.2 x 3.2 cm black eschar wound bed

12. Left ischium 1 x 0.6 purple deep tissue injury.

13. Left distal pre-tibia 2.4 x 1.2 cm slough with venous stasis stain.

14. Left medial malleolus 1.8 x 1.3 cm purple unstageable wound bed, pink peri wound.

15. Left great toe 1 x 1 cm bright red

16. Left 5th MP head, 2 x 2 cm black wound bed, peri wound pink

17. Left medial heel, 1.3 x 1.3 cm black eschar to wound bed

18. Left lateral foot (cuboid), 2 x 2 cm deep tissue injury

19. Left lateral malleolus 1 x 1 cm purple deep tissue injury

20. Right lateral malleolus 1 x 0.7 black eschar to wound bed

21. Right lateral foot 3 x 1.9 black eschar to wound bed

22. Right 5th toe (entire toe) 4 x 2 black

These failures were determined to pose an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and document review, the Registered Nurses (RN) failed to consistently document accurate and descriptive skin assessments, failed to adequately provide nutritional support to pt #1, failed to maintain accurate weight records, failed to notify the physician and Registered Dietician inorder to meet the nutritional need of patient #1. These failures contributed to the development of additional skin breakdown, severe weight loss (74.8 lbs.), and continued aspiration.

Refer to Tag A 395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and document review, the Registered Nurses (RN) failed to consistently document accurate and descriptive skin assessments, failed to adequately provide nutritional support to pt #1, failed to maintain accurate weight records, failed to notify the physician and Registered Dietician inorder to meet the nutritional need of patient #1. These failures contributed to the development of additional skin breakdown, severe weight loss (74.8 lbs.), and continued aspiration.

On 2/26/2013, at 1:00 PM, the medical record for patient (pt) #1 was reviewed and revealed the following:

Pt #1 was a[AGE] years old patient, admitted on [DATE] from a local long term care facility.

The chief complaint for admission was vomiting of coffle-grounds emesis and shortness of breath (SOB). He was admitted through the hospitals Emergency Department with a diagnosis of [DIAGNOSES REDACTED]

Pt #1's past medical history included cardiovascular accident (CVA), coronary artery disease (CAD), hypertension (HTN), gastrointestinal (GI) bleed, congestive heart failure (CHF), renal failure, chronic obstructive pulmonary disease (COPD), dementia.

His admission weight (wt.) was 267 pounds (lbs). He was disoriented/demented with decreased range of motion in both upper and lower extremities (early contractures). Also noted by the admitting physician was "There are no family members to discuss the patient's condition".

The long term care facility discharged pt #1 to the acute hospital with documentation of two (2) unstaged wounds, (sacrum and left heel)

Further review of pt #1 MR revealed that a swallowing study was conducted by the licensed speech language pathologist on 12/4/2013, and revealed the following: "The patient demonstrated a severe sensory/motor oral dysphasia. Recommendations: 1) nothing by mouth, 2) Alternate means of nutrition and medication and 3) Speech therapy to address deficits." The RD recommended Jevity per PEG tube at 55 Milliliters if tolerated by pt #1. At 55 ml per hour pt #1"s nutritional needs would be met.

On 12/6/2013, pt #1 had placement of a percutaneous gastric feeding tube (PEG) conducted by staff #19. The documented plan was placement of a PEG tube for dysphasia related to multi-infarct dementia, history of multi-infarct dementia and urinary tract infection.

On 2/27/2014, at 2:00 PM, in the office, an interview with staff #9 revealed that the Registered Dietician submitted the request for a wound consult following the swallowing study and placement of the PEG tube.

Staff #20 conducted a wound consult and dictated the following: "No popliteal pulses were palpable in the left leg. There were no ulcers in the lower legs or right foot. An unstageable pressure ulcer of the left heel approximately 2 cm (centimeters) in diameter. An Unstageable sacral pressure ulcer, relatively small at this time, approximately 3 x 4 cm in dimensions". Staff #20 failed to order specific pressure relief mechanism for pt #1.

Review of MR for Pt #1's initial skin assessment revealed two (2) photographs dated 11/30/2013 identifying the sacral area and left heel. This was confirmed by staff #4 and #6.

Review of the MR document titled "Pressure Ulcer Prevention Program (PUPP) Standardized Form to Support Admission Documentation" indicated that the Admission RN, staff #21, identified the location of the pressure ulcers as, #1 "foot" and #2 "Coccyx". RN #21 failed to complete the form and failed to document staging of the wounds, size (length, width and depth), undermining or tracking, exudate (drainage), peri-wound observations. This form, dated of 11/29/2013 and timed 2030 (military time), documented only the number of pressure wounds as "2". This was also confirmed by staff #5.

Nursing documentation revealed these two wounds from 11/7/2013 until the day of discharge on 1/7/2014. However, nursing documentation indicated other areas of skin break down which were not assessed consistently and were not resolved prior to discharge. Examples of nursing documentation for these other areas of skin break down were as follows:

On 12/10/2013, at 2345, staff nurse #22 documented "water blister, arm, upper Right anterior. Heel left pressure ulcer, Sacral pressure ulcer stage II". This wound was not re-assessed and was not resolved based on nursing documentation.

On 12/13/2013, at 1002, staff nurse #27 documented "red rash" and "left heel pressure ulcer and right hip pressure ulcer stage III". This was the first indication of a hip wound. This wound was not assessed again and was not resolved based on nursing documentation. At 1935, staff #23 documented "Patient has red splotchy rash over arms. abdomen, and upper legs, and discoloration to lower legs as well as generalized bruising over arms, left heel pressure ulcer and sacral pressure ulcer stage III". There was no documentation to explain the generalized bruising and no resolution documented in the nurses documentation.

On 12/14/2013, at 1930, staff #28 documented a Braden score of 15/23. A score of 15 indicates moderate need for pressure relief and risk for skin break down. Staff #28 failed to document assessment of pt #1 rash and documented "no skin lesions".

On 12/15/2013, at 0723, staff #27 documented "Redness, sores, ulcerations. Rash all over body, which is improving. Blisters to upper left back. Pressure ulcer to left and right heel, stage III pressure ulcer to sacral (sic)". These wounds were not resolved based on documentation. At 1945, staff RN #25 documented "Redness, bruising, sores, ulceration, Rash to body which has greatly improved. [DIAGNOSES REDACTED] to upper left arm and blisters to upper left back. Pressure ulcer to left and right heel and pressure ulcer stage III to sacral (sic)." Both nurses documented the red skin rash but failed to assess the sores, ulcerations and blister. Documentation simply established the fact that the sores, ulcerations and blisters were present.

On 12/16/2013, at 0830, staff RN #29 documented "ulcerations, unable to stage on bilateral heals and coccyx, sacrum and buttocks". Nursing documentation revealed the presence of two wounds (Coccyx and foot) on admission and there were 5 wounds (bilateral heels, coccyx, sacrum and buttocks) identified based on the documentation.

On 12/19/2013, at 1900, staff nurse #31 documented "skin bruises, ulcerations stage II to coccyx and unstageable area to right heel, stage II wound to left heel". No other skin assessment was documented and no other previously documented skin irritation was resolved.

On 12/20/2013, at 0745, staff RN #33 documented "skin bruises, ulcerations, left heel pressure ulcer stage II, right heel pressure ulcer, sacral pressure ulcers stage III". At 2100 Staff #34 documented "skin color normal, signs and symptoms, none. No lesions noted". Staff #34 failed to assess pt #1 skin condition.

On 12/23/2013, at 0800, Staff #22 documented skin color normal for patient, ulcerations left and right heel pressure ulcers, right hip pressure ulcer". At 1946, staff RN #36 documented skin warm, intact, moist color normal for patient. Encourage oral fluids (patient was NPO, PEG Tube in place). Sacral pressure ulcer stage III". Both nurses failed to perform a thorough, and complete skin assessment with description of the findings.

On 12/24/2013, at 0828, staff RN #33 documented skin color normal for patient, ulcerations, encourage oral fluids (patient was NPO-PEG Tube in place). Left and right heel pressure ulcers, sacral pressure ulcer stage III". Staff #33 failed to perform a thorough, and complete skin assessment with description of the findings.

On 12/26/2013, at 1930, Staff RN #37 documented skin warm, dry skin color normal for patient, turgor loose, moist, ulcerations. Heel pressure sore is black in color. Left and right heels stage II pressure ulcers, sacral pressure ulcer stage IV". Nursing documentation revealed inconsistency in staging and describing pt #1 wounds.

On 12/27/2013, at 0755, staff RN #38 documented in the Braden scale, "Nutrition is excellent. (The PEG tube formula, Jevity, was not tolerated at the Registered Dietician's suggested rate of 55 millimeters (ml) per hour. Beginning the third day after the Jevity was started it was reduced by nursing staff to 25 ml. This rate does not meet the nutritional needs of pt #1) skin warm, dry, normal for patient, stage 3 to coccyx...No lesions noted.". No indication in the medical record that the RD or the MD was notified.

On 12/28/2012, at 0755, staff RN#38 documented "Skin dry, warm normal for patient fragile redness unstageable decubitus (sic) to coccyx...no lesions noted". Staff failed to perform a thoroughto evaluation of pt #1 skin condition.

On 12/29/2013, at 0800, staff RN #38 documented "Skin break down to right thigh pink, wounds to both heels...unstageable decubitus(sic) to buttock". The skin breakdown to right thigh was not asessed again and not resolved based on nursing documentation.

On 12/30/2013, at 0714, staff nurse #35 documented "Skin warm and dry, normal for patient, left and right heel stage II pressure ulcer, sacral pressure ulcer stage III". At 1920, staff RN #34 documented "skin warm, dry, normal; for patient turgor normal right and left heel wound and wound lower spine". The wound to the lower spine was not assessed again, nor resolved based on the nurses notes.

On 1/1/2014, there was no nursing assessment of pt #1 skin breakdown documented in the MR for the first shift. At 1930, staff #34 documented left and right heel wound and sacral wound". No other skin assessment was documented by the nurse.

On 1/2/2014, staff nurse #22 documented "discoloration noted to last two toes right foot, left and right heel pressure ulcer stage II sacral pressure ulcer stage III. Also pt with several stage 3 black wounds on bilateral feet also with abrasion of left lower inner leg dressing changed as ordered". This was the first and only time wounds to pt #1's bilateral feet, right toes, and lower inner leg were documented. All areas were documented as covered with black eschar by the long term care facility.

On 1/3/2014, staff nurse #35 documented "left and right heel pressure ulcers stage II and sacral pressure ulcer stage III". At 2000, staff RN #39 documented the Braden scale and nothing further. Staff #39 documented "No lesions noted". Both nurses failed to perform a complete, accurate and descriptive skin assessment.

On 1/4/2014, at 0729, staff nurse #35 documented "right foot pressure ulcer, left and right heel pressure ulcer stage II, Right anterior thigh pressure ulcer stage II, sacral pressure ulcer stage III". At 2000, staff #39 documented the Braden scale and no further skin assessment was recorded. Staff #39 again failed to perform a thorough complete skin assessment.

On 1/5/2014, at 0714, staff #35 documented "right foot pressure ulcer blisters, left and right heel pressure ulcer stage II, Right hip pressure stage II and sacral pressure ulcers stage III". At 2020, Staff RN #39 documented the Braden scale only. No further assessment of pt #1 skin was recorded.

On 1/6/2014, at 0800, staff RN #38 documented the Braden scale. Stage 4 to coccyx, stage 2 to both heels, dressing changed by night nurse". No second shift skin assessment was documented.

On 1/7/ , at 0730, staff #38 documented the Braden scale and "Multiple abrasions all over body. Stage 3 to coccyx... both heels stage 2". At 1800 staff #38 documented Santyl dressing to coccyx...painted both heels with betadine...". Both nurses failed to perform a thorough, accurate and complete assesment of pt #1 skin condition prior to discharge.

A review of the discharge instructions read as follows: Instructions #2: Wound/incision care group note: Santyl dressing to coccyx wet to dry daily and paint both heels with betadine solution daily cover with Kerlix. The discharge instructions failed to describe or instruct the care of the multiple other areas of skin break down (mid back, multiple foot/toe wounds, lower leg, hips)

On 2/27/2014 facility policies were reviewed and revealed the following:

Patient Care Services Guidelines: Titled "Interdisciplinary Documentation/Patient focused: Item II Patient EMR: A. Initial assessment must be performed by a Registered Nurse. Evaluations are performed every shift and whenever a change of condition is noted by a licensed nurse....Braden scale for skin assessment risk should be filled out completely each 12 hour shift".

Patient Care Services Guidelines: Titled "Photographic Documentation; Item V-Photos will be taken of: A.) Skin tears, significant cuts or bruising, ulcers of any stage 1-6 or areas that are suspected ulcers. Photographs will be taken upon admission and not taken again unless the physician orders it".

On 2/26/2014, in the office the following facility policy Guidelines were reviewed:

Patient Care Services Guidelines: Titled "Prevention of Alteration in Skin Integrity revised October 2013:

Item "B" Request pressure relief device (i.e. overlay, Clinitron) use heel and elbow protectors as needed. If patient requires specialty mattress on bed and can be up in chair then chair needs support cushion.

Item "R" Education of patient, family or significant other and document in teaching section of Electronic Medical Record (EMR)".

After review of the facility policies it was determined that the facility had no policy instructing the nursing staff concerning accurate, descriptive documentation of skin break down or actual pressure wounds..

Pt #1 was discharged from the acute care facility and admitted to a long term care (LTC) facility on 1/7/2014.

On 2/27/2014, at 4:15 PM, in the conference room of the LTC facility, pt #1's admission MR was reviewed.

Admission documentation dated 1/7/2014 recorded pt #1's admission weight was 192.2 pounds (a 74.8 pound weight loss from the 11/29/2013 hospital admission weight of 267 pounds).

Also the LTC facility documented twenty two (22) areas of skin break down. They are as follows:

1. Right mid back 2 x 1.5 Centimeter (cm) unstageable with slough.

2. Sacral area 11.5 x 6.5 cm unstageable, black/brown eschar to wound bed with slough, 1 cm undermining, slight odor.

3. Right trochanter 7.5 x 4.7 cm purple, deep tissue injury.

4. Right trochanter 4 x 4 cm, covered with black/brown eschar to wound bed, peri wound area red.

5. Right lateral foot (cuboid) 1.5 x 0.8 cm black eschar to wound.

6. Right 5th metaphylangel head (MP), 3.3 x 2 cm black eschar covering wound bed.

7. Right great toe medial aspect 1 x 1 cm Red

8. Right MP head 2 x 1.7 cm deep tissue injury

9. Right medial foot 1.7 0.7 cm purple, deep tissue injury

10. Right lateral heel 2.5 x 1.5 cm black eschar wound bed

11. Right medial heel 5.2 x 3.2 cm black eschar wound bed

12. Left ischium 1 x 0.6 purple deep tissue injury.

13. Left distal pre-tibia 2.4 x 1.2 cm slough with venous stasis stain.

14. Left medial malleolus 1.8 x 1.3 cm purple unstageable wound bed, pink peri wound.

15. Left great toe 1 x 1 cm bright red

16. Left 5th MP head, 2 x 2 cm black wound bed, peri wound pink

17. Left medial heel, 1.3 x 1.3 cm black eschar to wound bed

18. Left lateral foot (cuboid), 2 x 2 cm deep tissue injury

19. Left lateral malleolus 1 x 1 cm purple deep tissue injury

20. Right lateral malleolus 1 x 0.7 black eschar to wound bed

21. Right lateral foot 3 x 1.9 black eschar to wound bed

22. Right 5th toe (entire toe) 4 x 2 black

These failures were determined to pose an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.