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Based on record review and interview, the facility failed to ensure RNs (registered nurses) evaluated the nursing care needs for 3 of 5 patients (#'s 1, 2, and 12) reviewed with pressure ulcers (PU) .

- RNs provided PU treatments without physician's orders for Patient #'s 1, 2, and #12.

-RNs did not provide PU treatments as ordered by physicians for Patient #2.

-RNs did not notify the physician or Wound Care Nurse on changes in PU or when new PU developed for Patient #'s 1 and 2.

-RNs did not consistently assess PUs or accurately document that assessment for Patient #'s 1, 2, and 12.

Findings include:

Patient #1

Record review of Patient #1's closed electronic History and Physical dated 5/29/14 revealed he was admitted on [DATE] with abdominal distention, abdominal pain and constipation for at least 4 days. He did not have any rashes or ulcers. The plan was possible colon surgery.

Record review of Patient #1's room assignments during his stay revealed the following:

IMCU (Intermediate Medical Care Unit) 0 5/29/14 to 6/11/14
MICU (Medical Intensive Care Unit) 6/11/14 - 6/17/14
SCU (Surgical Care Unit) 6/17/14 to discharge on 6/25/14

Record review of Patient #1's Nurses' Notes with Risk Manager #52 revealed the following documentation:

5/29/14 - Skin within normal limits. dry and intact
6/6/14 - Skin not intact, but no PU
6/8/14 - Skin not intact, but no PU
6/14/14 - Middle lower sacrum with blister (Stage II PU). Measured 2 cm x 1 cm. Cleaned and applied Allevyn foam.
6/16/14 - Tear (Risk Manager #52 said this meant the blister opened). Draining, linear with "strong odor".
Measurements during this time were 2 cm x 1 cm. There were no further measurements until 6/20/14.
6/20/14 - The wound measured 5 cm x 4 cm with purulent strong odor.
6/21/14 - There was necrotic tissue
6/23/14 - The wound was noted to be a Stage III with strong odor.

No measurements were taken from 6/20/14 to discharge on 6/25/14.

Record review of the Patient's Wound Care Note dated 6/18/14 revealed the following:
"(Wound Care) nurse asked to see pt (patient) for wounds to the sacral area. Pt has a stage 2 pressure ulcer to the sacral area with pink tissue and scant serous drainage. Pt. sitting in chair without a chair cushion, pt will need waffle cushion while sitting up. Pt has foam dressing in place upon assessment and I agree with this treatment to be changed every 2 days.

Record review of Patient #1's Physician's Orders revealed treatment orders for the sacral wound were not written until 6/18/14, although staff were applying a treatment since 6/14/14. The wound order was to cleanse the sacral wound with wound cleaner, apply Allevyn gentle foam border dressing. From that date until discharge on 6/25/14, there was no other order for wound care or for another wound care nurse assessment. There were no orders for a sacral wound culture or for antibiotic therapy.

Interview on 11/5/14 at 9:50 a.m. with Risk Manager #52, she said the facility practice was for the nurse to do a full wound assessment including measurements when providing the treatment. She agreed the documentation for the wound assessment was inconsistent. She agreed treatments had been documented as being provided from 6/14/14 to 6/17/14 even though there were no physicians order for the treatment.

Record review of the Patient's lab reports revealed no sacral wound culture even though there was a strong smell to the wound starting on 6/16/14.

Record review of the facility's grievance log revealed one from Patent #1 on 7/30/14 labeled Medical Concern Issues.

During an interview on 11/5/14 at 1:05 a.m. with Risk Manager #52, she said the facility identified they had problems with wound care after Patient #1's grievance was investigated. She said they identified the nurses were providing treatments without a physician's order, there were holes in documentation and the nurses did not know how to initiate a consult from Wound Care Nurse #60. She said the following processes were put in place for the MICU (Medical Intensive Care Unit) nurses because that was where the patient was when he developed the pressure ulcer:
1. Wound Care Nurse #60 was to give presentation to the MICU nurses on PU prevention, treatment of PU and documentation.
2. Wound Care Nurse #60 was to educate the nurses on the Braden Scale.
3. The nurses were to be trained on how to initiate a wound care consult.
4. A presentation on Hospital Acquired PU was to be presented at unit staff meetings in November 2014.

Patient #2

Record review of Patient #2's current electronic medical record revealed she was admitted on [DATE].

Record review of Patient #2's Nurses' Notes for Skin Abnormality/Wounds dated 9/25/14 revealed the following:

1. Right Posterior Leg stage III Pressure Ulcer (PU) wound measuring 3.5 cm x 3 cm x 0 cm.

2. Left Heel stage III PU wound measuring 4 cm x 3 cm x 0 cm

3. Middle Buttock skin tear

4. Right Inner thigh skin tear.

Record review of Patient #2's Wound Care Note dated 9/26/14 revealed Wound Care Nurse #60 evaluated the left heel and right lateral leg. The left heel was a stage III PU with red granular base and small amount of drainage. The right lateral leg had a full thickness necrotic wound with slough in the base. He recommended Fibracol collagen dressing and Allevyn foam to the left heel to be changed Monday, Wednesday, and Friday. He recommended Medihoney gel and non-adherent pad to the right lateral leg. There was no mention of the middle buttock or right inner thigh skin tears.

Record review of Patient #2's Physician's Orders revealed the following:

9/26/14 - Clean right lateral leg with wound cleaner. Apply Medihoney gel and cover with non-adherent pad, kerlex and tape. Change daily.

9/26/14 - Clean left heel with wound cleaner. Apply cut fibercol to size of wound, cover with Allevyn foam Monday, Wednesday, and Friday.

Further review of the Nurses' Notes for Skin Abnormality/Wounds revealed the following:

9/26/14 - Sacral wound tear that measured 3 cm x 0.4 cm. The wound was not measured on 10/28 or 10/29/14.

There was no documentation of any wounds for 9/30, 10/1 and 10/2/14.

10/3/14 - 1/5/14

1. Right Posterior leg wound measured 3.5 cm x 3 cm x 0.5 cm until 10/5/14 when it enlarged to 4 cm x 4 cm x 1 cm. Medihoney was being used. There were no measurements from 10/6 through 10/12/14 (7 days). The wound was described as being necrotic starting on 10/9/14. On 10/12/14 the wound measured 3 cm x 2.5 cm x 0 cm. On 10/15 and 10/16/14 the wound measured 3.5 cm x 3 cm x 0.5 cm. On 10/21/14 and 10/22/14 Medihoney was used. On 10/25/14 and 10/30/14 the treatment changed to Allevyn foam. From 10/24/14 to 11/1/14 the wound measured 2 cm x 1.5 cm x 0.3 cm. 11/3/14 at 8:00 a.m. the wound measured 0.9 cm x 0.5 cm x 0 cm. By 3:40 p.m. the wound enlarged to 3 cm x 2 cm x 0.2 cm. On 11/3/14 the treatment changed from Allevyn foam to damp to dry gauze dressing.

Per the Physician's Order the wound was to be cleaned daily and the dressing changed. The wound was no documented as being cleaned and treated on the following days 2014:
9/26, 9/27, 9/28, 10/4, 10/6, 10/7, 10/8, 10/10, 10/11, 10/13, 10/15, 10/16, 10/18, 10/19, 10/20, 10/22, 10/27, 10/29, 10/30, 11/1, 11/2, and 11/3.

2. Right Heel - Facility acquired
On 10/1/14 there was documentation of a scab on the right heel. By 10/13/14 the PU wound measured 3 cm x 3 cm x 0 cm. Wound foam was being used.

3. Right anterior foot - Facility acquired
On 10/5/14 the wound measured 1 cm x 1 cm x 0.5 cm and noted to be a Stage II PU. On 10/17/14 the wound was cleaned with wound cleaner and Allevyn was applied. On 10/22/14 the wound measured 2.5 cm x 1 cm x .1 cm. Medihoney was applied to the wound.

4. Middle buttocks
This wound went from a tear to a fissure to a stage II from 9/26/14 to 10/5/14. On 10/5/14 it measured 1 cm x 1 cm x .5 cm. On 10/10/14 there was documentation Allevyn was used to treat the wound.

Further review of the Physician's Orders revealed no orders for treatments for the right heel, the right anterior foot, or the middle buttocks. There were no orders to change the treatments on the right posterior leg wound.

Patient #12

Record review of Patient #12's current electronic medical record revealed he was admitted to the facility on [DATE] with a surgical wound, but no pressure ulcer (PU) identified.

Record review of Patient #12's nurses' notes on 10/15/14 at 2000 with Health Care Improvement Coordinator #59 revealed an unstaged sacral PU measuring at 2 cm x 2 cm.

Further record review of Patient #12's nurses' notes revealed the following:

10/16/14 at 0800 revealed PU was open to air (OTA) with an Allevyn dressing applied (If a dressing is applied, it cannot be open to air). An additional nurses' notes at 0800 revealed an unstaged PU with edges approximated with partial thickness, [DIAGNOSES REDACTED], nonblanchable measuring at 2 cm x 2 cm x 1 cm.

10/17/14 at 2400 revealed PU was OTA, assessed, cleaned with Zinc Oxide and Allevyn dressing reapplied. Additional nurses' notes at 0800 revealed PU was OTA, unstageable, with non removable dressing with a measurement of 4 cm x 2 cm. At 2000 nurses' notes reveals non removable dressing with a measurement of 4 cm x 2 cm.

10/18/14 at 2000 revealed PU was 4 cm x 2 cm, with nonremovable dressing in use.

10/20/14 at 0200 revealed PU was 2 cm x 2 cm. Additional nurses' notes at 2000 reveals PU was 2 cm x 2 cm.

10/22/14 at 0730 revealed PU was 3 cm x 3 cm that was maroon with 0.5 cm x 0.5 cm area Stage II at edges. Additional nurses' notes at 2000 revealed PU was 3 cm x 3 cm.

10/23/14 at 0830 revealed PU was a Stage II and measured 3 cm x 3 cm. Additional nurses' notes at 2000 revealed PU was moist, pink and red and measured 3 cm x 3 cm.

10/24/14 at 0800 and 2000 revealed PU was pink/red scab at a Stage II. The 2000 nurses' notes does not reveal PU's color. The measurements on both the 0800 and 2000 nurses' notes reveal that the measurements were 0 cm x 0 cm. The nurses' notes on 10/25/14 and 10/26/14 also has the PU measurements as 0 cm x 0 cm.

10/27/14 at 2020 revealed that the PU's measurements were 0.3 cm x 0.2 cm x 0.2 cm.

10/28/14 and 10/29/14 revealed that the PU's measurements were 0 cm and that there was partial thickness.

11/1/14 revealed PU was a Stage II and was covered with an Allevyn dressing and was unable to assess.

From 11/2/14 to 11/6/14 revealed PU was a Stage II and they were unable to assess, but there was a measurement documented on 11/6/14 as 0 cm X 0 cm. There was no documentation that the wound was healed.

Record review of Patient #12's Physician's Orders revealed no wound care orders to treat the sacral PU. There was no Wound Care Consult from Wound Care Nurse #60. This was verified by Health Care Improvement Coordinator #59.

Interview on 11/5/14 at 2:00 p.m. on IMCU (Intermediate Care Unit) with RN #57, she said she would get an order from the patient's physician for wound care if a patient admitted with a PU. She said the wound would be measured and assessed whenever a treatment was provided. She said if the PU worsened or a new PU developed, then she would call the physician and she could ask Wound Care Nurse #60 to assess the PU. She said the only thing that had changed recently in regards to wound care was that Wound Care Nurse #60 was providing re-training on PU care.

Interview on 11/6/14 at 9:30 a.m. on MICU (Medical Intensive Care Unit) with RN #62, she said the RNs were responsible for checking patient's skin for PU and if present, to provide treatments for PUs. She said the RNs were responsible for measuring the PU each shift. She said the facility had a mandatory wound care class that she had not attended yet.

Interview on 11/6/14 at 9:40 a.m. on MICU with RN #63, she said if a patient had a PU it would be assessed by the Wound Care Nurse and the RNs would provide the treatment. She said the wound would be measured with each treatment.

Interview on 11/6/14 at 10:15 a.m. on SCU (Surgical Care Unit) with RN #66, she said PU treatments would be as ordered by the physician and as needed for soiling. She said the wound would be assessed and the physician notified for an order for treatment. She said the RNs were responsible for providing the treatments. She said if the RNs were not sure of an assessment or had any questions, they could call the Wound Care Nurse. If they saw any changes in the wound, the RN would call the physician. She said the RNs could call the Wound Care Nurse at any time.

During an interview on 11/6/14 at 3:30 p.m. with Wound Care Nurse #60, he said the 0 x 0 measurement would have been put in by the computer automatically for a weekly assessment and measurement. When Wound Care Nurse #60 was informed that the RNs were assessing and measuring the wound with each treatment or on each shift, he said the PU only needed to be measured weekly. When he was asked who would be responsible for the assessment and measurement and on what day, he did not have an answer.

Interview on 11/6/14 at 4:30 p.m. with Interim CNO #50, she said the facility was still in the process of training staff on the areas identified with Patient #1's grievance. When she was asked what type of monitoring was being done to ensure the RN's were providing appropriate PU care, she said she had not started monitoring because not all RNs had been trained yet. When she was asked if the areas identified on the record reviews of Patient's #1, #2, and #12 were all Standard of Practice and what every RN should be doing already, she agreed they were.

Record review of the facility's Policy and Procedure (P&P) for Pressure Ulcer Management dated 2/7/12 revealed the following:

Having an established guideline on the management of pressure ulcers provides licensed personnel a means to develop and implement a patient-specific care plan following evidence-based practice.

Identify individuals at risk for developing pressure ulcers and initiate early prevention interventions

Maintain intact skin

Consult the Multidisciplinary Team...

1. Conduct a pressure ulcer and skin alteration assessment for all patients on admission and daily.

2. ....Initiate early prevention and maintain intact skin by following the recommended interventions..."

Number 3 had the nurse consult Addendum A or the Clinical Practice Quick Reference Guide for wound care recommendations. Number 4 was a referral to Addendum B for assistance with support surface options. Both instructed the nurse to consult the primary physician, obtain wound care order from the physician, and to document interventions each shift on the EMR (Electronic Medical Record).

"5. Consult the multidisciplinary team based on patient assessment for prevention and management of pressure ulcers, i.e.; Physician, PA-C (Certified Physician Assistant), ANP (Advanced Nurse Practitioner), WOCN (Wound ostomy Continence Nurses), Nutritionist, Diabetic Educator, PT and OT (Physical and Occupational Therapy)....

7. Notify Physician, PA-C, or ANP if the skin/wound condition worsens..."