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Based on medical record review and interviews, the hospital failed to implement and revise interventions in Patient Identifier # 1's (PI # 1) plan of care to include interventions for wound care and weight.
PI # 1 was admitted to the hospital with an identified Stage II pressure ulcer but wound measurements were not documented on admission (4/18/2011) or on 4/20/2011, 4/23/2011, 4/25/2011 and 4/29/2011;
On 4/19/2011, the physician changed the order for pI# 1's weights from weekly to weights three times per week. The care plan was not updated to reflect the change in the physician's order.
This deficient practice affected PI # 1, one of ten sampled patients.
Findings Include:

According to the History and Physical, PI # 1 was admitted to the hospital on April 18, 2011 with diagnoses to include Fall with Fracture, Multiple Contusions and Possible Cognitive Impairment. The Medical History includes Chronic Kidney Disease, Type II Diabetes and Coronary Artery Disease.

A review of the Wound Addendum/Status Update dated 4/18/2011 reveals a Stage II pressure ulcer was identified on admission. However, no wound measurements are documented on the Addendum during PI # 1's entire hospitalization from 4/18/2011 through 4/29/2011.

The Interdisciplinary Plan of Care dated 4/18/2011 documents, "Actual skin breakdown" as a "Stage II buttocks." Measurements of the wound are not included as an intervention. Hypertension is also identified as a problem. One of the interventions is to weight PI # 1 weekly.

A Physician's Order dated 4/19/2011 documents: Weigh every Monday, Wednesday and Friday.

The treatment plan documented in Physician's Progress notes dated:
4/19/2011 includes, "5. Continue with wound care."
4/21/2011 includes, "...Weigh three times a week to monitor for fluid overload."

The Interdisciplinary Plan of Care dated 4/23/2011 documents "No change since admission" in the condition of PI # 1's skin.

According to a review of the Graphic Sheets, no weight is documented for PI # 1 on 4/20, 4/22, 4/27 and 4/29/2011

A Physician Progress Note dated 4/22/2011 documents PI # 1's plan of care is to follow up on weight and monitor renal function.

The Wound Assessment, Prevention and Documentation Policy and Procedure, effective date 8/20/2010, reveals the purpose is:
1. To improve patients' skin integrity through timely and consistent clinical practices fro the assessment and prevention of wounds.
2. To ensure standards of documentation related to the assessment of skin and wounds.

Policy: All patients admitted to ...will be screened within 24 hours for the risk of skin breakdown and for alteration in skin integrity by a Registered Nurse.

Definition: The term wounds is used generically to include all types of alterations in skin integrity...various classification methodologies, interventions and documentation requirements are described...The general categories of wounds are pressure ulcers and procedure related wounds...

Assessment: All patients will have integument and wound inspections daily, weekly and as often as indicated.
1. Assess all patients for the risk of skin breakdown using the Braden scale.
a. Record findings:
1. Admission on the Interdisciplinary Assessment
2. Weekly on the Plan of Care...

Documentation: Stage II and greater pressure ulcers will also include the following:
1. Size: Length, Width and Depth should be recorded in centimeters on admission, weekly and at discharge...
Weekly documentation will include:
...6. Status update to be completed weekly and reflected in the plan of care..."

During an interview on 6/14/2001 at 4:00 PM, the Chief Executive Officer/Employee Identifier (EI) # 1, stated PI # 1's wound should have been measured and documented in the medical record.

On 6/15/2011 at 4:45 PM, the Chief Nursing Officer/ EI # 2, confirmed there are no measurements of PI # 1's wound in the medical record.

This citation written as a result of the investigation of complaint number AL00024327.