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.


Based on review of facility policy, review of a facility protocol, facility documentation, medical record review, and interview, the facility failed to follow a physician's order for a timely consult and failed to follow a facility pressure ulcer protocol for 1 patient (#1) of 3 patients reviewed for pressure ulcers.

The findings included:

Review of facility policy "Wound & [and] Skin Care" dated 9/2014 revealed "...provide a wound management program to minimize the development of facility acquired pressure ulcers and to provide guidelines to treat alterations in skin integrity in a timely consulted the CWOCN [certified wound ostomy continence nurse]...will evaluate the treatment plan and revise as necessary..."

Review of a facility protocol "Addendum A (Pressure Ulcer Management Protocol)," not dated, revealed a facility decision tree for management of patients with pressure ulcers. Further review revealed "...does patient have a pressure ulcer or deep tissue injury..." Continued review revealed if the answer was yes the facility was to " patient on pressure relief support [pressure reducing mattress]..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Medical record review of an Admission Assessment date 11/17/17 at 7:08 PM revealed the patient had abrasions and bruising to his buttocks with no open areas.

Medical record review of a nurse's note dated 11/24/17 at 7:01 AM revealed "...redness to buttocks...barrier cream ointment applied...Braden score 11 [increased risk for pressure ulcer development]..."

Medical record review of a physician's order dated 11/27/17 at 7:01 AM revealed "...consult to wound care..."

Medical record review revealed a Wound Care Consult was ordered on [DATE] at 7:01 AM. Further review revealed the wound care consult was not completed until 12/5/17 (9 days after the consult was ordered).

Medical record review of a Wound Care Consult dated 12/5/17, not timed, revealed "...he [Patient #1] has a 9 cm L [centimeter length] x [by] 15 cm W [wide] eschar [dead tissue] covered ulcer over his sacrum...there is a small 2 cm partial thickness ulcer over his right gluteal fold [buttocks] and another the same size over the left gluteal fold...impression: pressure ulcer nosocomial. Stage 2 [partial thickness skin loss] of the right and left gluteal fold...unstageable to sacrum..." Continued review revealed the patient was not placed on a specialty pressure reducing mattress until 12/13/17 (20 days later).

Interview with the Wound Care Nurse, on 8/30/18 at 3:25 PM, in the conference room, revealed "...the consult was ordered on [DATE]...the nurses do not stage the wounds, wound care does that. The patient had developed some redness and drainage along the cleft of the buttocks...I assessed the wound on 12/5/17 and found the wound to be unstageable with [DIAGNOSES REDACTED] [redness] on the sacrum and he had two stage 2 [pressure ulcers] on the gluteal folds. At that time I was the only wound care nurse and I was on vacation that week. We did not have another nurse who did [wound care] assessments so I saw the patient when I came back the week after...the patient was unable to move himself, he was on the ventilator...was a diabetic. He was being followed by Nutrition and was receiving tube feedings...he was placed on a specialty bed on 12/13/17 to assist in the keeping the patient off the wound..." Further interview confirmed the wound care consult was not performed until 9 days after the wound care consult was ordered.

Interview with the Intensive Care Unit (ICU) Clinical Leader on 8/31/18 at 1:05 PM, in the conference room, revealed the nursing staff identified the skin breakdown on 11/27/17 and a wound care consult was requested. Further interview confirmed "...the wound care nurse was on vacation...wound care does not work on the weekends...wound care did not see the patient until 12/5/17.

In summary, the facility failed to ensure a physician's order for a wound care consult for Patient #1 was completed timely and failed to follow a facility decision tree for timely placement of pressure relief support for Patient #1.