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Based on interview and medical record review it was determined the Hospital failed to ensure areas of skin breakdown were appropriately assessed, staged and treated and that turning/repositioning was provided as needed and personal hygiene needs were consistently provided in one (Patient #1) of 10 medical records reviewed.

Findings included:

1.) Documentation indicated Patient #1 was transferred to Hospital #2's Emergency Department, on 10/27/11 for a gastrostomy tube change. Hospital #2 10/27/11-10/28/11 documentation indicated Pateint #1 had a pressure wound identified on the left buttock that was classified as a Stage II pressure wound and a pressure wound identified on the right buttock, classified as a Stage II.

Review of Hospital #1's nursing documentation did not indicated the pressure wound of Patient #1's buttock was identified and/or staged.

The Director of Quality Management was interviewed by telephone on 12/12/11 at 2:00 PM. She said nursing staff felt the area on Patient #1's buttock was small and was under control with the care/treatment being performed on the area. She said nursing staff did not consult the Skin Care Nurse.

2.) Review of Patient #1's clinical record indicated Pateint #1 was on bed rest and required maximum assistance with turning and repositioning. On admission of 7/28/11 Pateint #1 had pressure areas identified on the heels and coccyx. Heel pillows were utilized during the whole admission to elevate and reduce weight on Pateint #1's heels.

Review of 7/29/11 nursing flowsheet documentation indicated between the hours of 3:00 PM and 8:00 PM Patient #1 was not turned/repositioned.

Review of 7/30/11 nursing flowsheet documentation indicated between the hours of 6:00 A.M. and 10:00 A.M. Patient #1 was not turned/repositioned. Pateint #1 remained on his/her back with an occasional boost up in bed for most of the day and evening.

Review of 7/31/11 nursing flowsheet documentation indicated from midnight until 5:00 P.M. Patient #1 was not turned/repositioned.

Review of nursing flowsheet documentation indicated from 3:00 P.M. to 11:00 P.M. on 8/6/11 Patient #1 was not turned/repositioned. There was a skin tear identified on Patient's left buttock on 8/11/11.

Review of 8/13/11 nursing flowsheet documentation indicated Patient #1 remained on his/her back for all but 2 hours during the 24 hour period and was boosted up in the bed at various times.

Review of nursing flowsheet documentation indicated Pateint #1 remained on his/her back from 5:00 A.M.-until 6:00 P.M. on 8/16/11, 5:00 A.M..-11:00 P.M. on 8/17/11, 1:00 AM-9:00 PM on 8/19/11 with an occasional boost up in the bed, with no documentation as to why.

Review of nursing flowsheet documentation indicated Pateint #1 still required maximum assistance with turning/repositioning however he/she was left to independently turn/reposition by the assigned nursing staff on 8/22/11 between midnight and 5:00 A.M. and on 8/23/11 between midnight and 5:00 A.M.

Review of nursing flowsheet documentation indicated Pateint #1 was not turned/repositioned while in bed at any time on 8/26/11 between 8:00 A.M. and 8:00 P.M.

Review of 9/5/11 Nursing flowsheet documentation indicated Patient #1 continued to require maximum assistance with turning/repositioning. Nursing staff assigned to provide Patient #1's care did not turn and reposition Pateint #1 but classified him/her as independently tuning/repositioning on 8/27/11, between 3:00 A.M. and 6:00 A.M. 1

Review of nursing flowsheet documentation indicated Patient #1 was not turned/repositioned on 8/28/11 between 6:00 A.M. and 10:21 A.M. and between 8:40 PM and 11:00 P.M. On 8/29/11 Patient #1 was not turned between 6:00 AM. and 8:00 P.M. He/She was also not turned/repositioned on 8/30/11 between 4:00 PM and 1:00 A.M. on 8/31/11.

Review of 9/3/11 nursing flowsheet documentation indicated Pateint #1 was not turned repositioned for 6 hour.

Review of Nursing flowsheet documentation indicated Patient #1 continued to require maximum assistance with turning/repositioning. Nursing staff assigned to provide Patient #1's care, on 9/5/11 between 7:15 A.M. and 3:00 PM, did not turn and reposition Pateint #1 but classified him/her as independently tuning/repositioning.

Review of 9/14/11 nursing flowsheet documentation indicated Patient #1 was not turned/repositioned between midnight and 7:15 AM or between 7:00 P.M. and 11:00 P.M.

Review of 9/16/11 nursing flowsheet documentation indicated there was a blister on Pateint #1's left heel filled with a dark color fluid. Patient #1 was not turned/repositioned between 1:40 P.M. and 8:00 P.M.

Review of 9/18/11 nursing flowsheet documentation indicated Patient #1 was not turned/repositioned between 9:00 AM and 4:00 PM.

Review of 9/21/11 nursing flowsheet documentation indicated there was a large blood filled blister on the left heel. a dressing was applied.


Review of 9/23/11 nursing flowsheet documentation indicated Patient #1 continued to require maximum assistance with turning and repositioning. Nursing staff did not turn and reposition Pateint #1 at any time between midnight -9:00 A.M. and 10:00 A.M.-4:00 PM.


Review of 9/25/11 nursing flowsheet documentation indicated Patient #1 required maximum assistance with tuning/repositioning. Patient #1 between midnight - 5:00 AM was left to independently turn/reposition him/herself and between 3:00 PM and 11:00 PM was not turned or repositioned.

Review of 9/30/11 nursing flowsheet documentation indicated Patient #1 was not turned/repositioned at any time between midnight-8:00 AM and 7:00 PM-11:00 PM.

Review of nursing flowsheet documentation indicated Pateint #1 was not turned/repositioned at any time on 10/6/11 between 2:00 PM and 10:00 PM and on 10/15/11 between midnight and 8:00 AM. Patient #1 was also not turned/repositioned for 7 hours on 10/17/11 and 6 hours on 10/19/11 and on 10/20/11.

3.) Staff Register Nurse (RN #2) was interviewed in person on 12/1/11 at 8:30 AM. RN #2 said all patients are given a bed bath in the morning.

Review of 7/28/11-10/27/11 nursing flowsheet documentation indicated Patient #1 did not ambulate, was bed fast and totally dependent on nursing staff for bed baths and shampoos. Patient #1 was given a bed bath only 8 times (8/2/11, 8/10/11, 8/16/11, 8/20/11, 9/4/11, 9/7/11, 10/13/11 and 10/14/11) during the 3 month hospitalization and a shampoo was never provided.

Based on documentation review it was determined the Hospital failed to ensure a nursing care plan was developed and addressed patient's ongoing needs in one (Pt #1) or 10 medical records reviewed.

Findings included:

Medical record documentation indicated Patient #1 was admitted with a primary diagnosis of respiratory failure, had a tracheostomy and ventilator support. Patient #1 medical history included morbid obese, anasarca (generalized body swelling from retained fluid), diabetes, high blood pressure, lower extremity cellulitis and edema, high cholesterol, anxiety and depression.


Medical record review did not indicated a nursing care plan was initiated when Patient #1 was admitted on 7/27/11 nor was a nursing care plan ever developed to address Patient #1's continued needs.