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Based on clinical record review, policy review, observation, and interview, the facility failed to ensure Patient #1, #2, and #3 received proper incontinence care, and failed to manage the skin integrity of Patient #7 wherein the patient's wounds had not been measured since 04/16/10, of Patient #2 wherein wounds were not consistently documented, and of Patient #1 and #3 wherein their areas of impairment were not measured and a lack of turning to prevent said areas in each.

Findings Include:

Please refer to A0395, 482.23(b)(3) RN Supervision of Nursing Care for more information regarding the facility's failure to supervise nursing care.

Based on clinical record review, policy review, observation, family and staff interview the facility failed to supervise the nursing care for four patients with loss of skin integrity: Patient #1, #2, #3, and #7. The subsample of patients with impaired skin integrity was seven patients. The facility failed to supervise the hygiene needs for Patient #1, #2, and #3. The sample size was 10 patients. The facility census was 26.

Findings included:

Review of the medical record of patient #1 on 5/03/10 revealed this patient was admitted to the facility on 4/29/10 with skin wounds of the right stump post amputation, the right groin, and the lower and upper abdomen. Documentation dated 5/01/10 revealed the patient also had an "excoriation of the coccyx (tailbone area) that had denuded epithelium". There was no measurement of this area. This was confirmed by staff A on 5/03/10 at 3:00 PM. Review of the facility policy NSG 405 effective 9/14/07 revealed wounds are to be assessed upon admission and to include wound measurement. In addition, the wound care nurse called for frequent turning of the patient.



Further review of patient #1's record dated 4/30/10 revealed this patient had no evidence of being turned during the 7:00 PM to 7:00 AM shift. The record dated 5/01/10 for the 7:00 AM to 7:00 PM shift showed documentation the patient was turned at 8:00 AM and 10:00 AM. The medical record for the 7:00 PM to 7:00 AM shift on 5/01/10 did not show documented evidence the patient was turned.


In addition review of the medical record for this patient on 5/03/10 revealed no evidence of hygiene being provided on the 7:00 PM to 7:00 AM shift on 4/30/10 and on 5/01/10. Observation on 5/03/10 at 3:00 PM revealed the patient had a fecal bag and urinary catheter. When the patient was turned by the physician to his/her left side, the blue incontinence pad the patient was lying on had a large wet spot. The unmeasured coccyx wound noted by the nurse upon the patient's admission on 4/29/10 was first measured on 5/03/10 at 3:00 PM and was 3.4 by 6.5 by 0.1 centimeters in size.


Review of the medical record of patient #2 revealed this patient was admitted to the facility on 4/20/10. This patient was assessed on 4/21/10 as having pressure sores of the left buttock, posterior thigh, sacrum, right lower medial extremity and left lateral extremity. The wounds identified for this patient on 4/27/10 did not describe the wound areas at the same anatomical locations, therefore not showing consistency in wound descriptions.

Review of patient #2's medical record on 5/04/10 also revealed that on 4/27/10 from 7:00 AM to 7:00 PM there was no evidence personal hygiene was provided for this patient. The documentation dated 4/28/10 revealed no evidence of personal hygiene provided for this patient from 7:00 PM to 7:00 AM. This confirmed by staff C on 5/05/10 at 10:15 AM.

Review of patient #7's medical record on 5/05/10 revealed this patient was admitted to the facility on 4/15/10. Identification of wounds by staff D on 4/16/10 revealed the patient had a coccyx (tailbone) wound measuring 1.7 by 1.7 by 0.1 centimeters. There has been no further assessment or measurements by the facility nursing staff documented of this pressure wound since 4/16/10. Another wound on the patient's right posterior thigh was identified by staff D on 4/16/10 that was measured to be 1 by 1 by 0.1 centimeter. There has been no further assessment including measurements by the facility nursing staff documented of this pressure wound since 4/16/10. In addition medical record review revealed documentation dated 5/04/10 that a small lesion was found on the patient's scrotum. There was no documentation this area was measured to determine a base line for this wound. These findings were confirmed by staff B on 5/05/10 at 2:30 PM.


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The clinical record review for Patient #3 was completed on 05/05/10. The clinical record review revealed Patient #3 was admitted to the hospital on 12/30/09 with admitting diagnoses of status post removal of a brain cyst, postoperative seizures, and respiratory failure. The clinical record review revealed a history and physical dated 12/31/09. The history and physical stated the patient was in his/her late 50s, had a medical history significant for congestive heart failure, chronic obstructive lung disease, and stated Patient #3 had a craniotomy (brain surgery) to remove a benign cyst on 12/15/09. The history and physical also stated that postoperatively the patient developed respiratory failure, seizures and was admitted with a tracheostomy and was receiving oxygen from a tracheostomy mask.

The clinical record review revealed an interdisciplinary admission data base dated 12/30/09 that stated Patient #3 was alert to person only, semiconscious, and had several functional impairments. The data based stated these impairments included the acts of bathing, dressing, feeding, and grooming. The data based stated other areas of impairment included moving about in the bed, transferring, and maintaining balance. The admission database stated the patient's only skin impairment was an incision on the scalp from the recent craniotomy. The admission database stated the patient was incontinent of liquid brown stool. The clinical record review reviewed revealed Patient #3 was incontinent of stool on each day of Patient #3's stay (12/30/09 to 01/06/10).

The clinical record review revealed a physician's order dated 01/04/10 at 7:30 A.M. to place a fecal management system and a nursing note dated 01/04/10 at 10:40 P.M. that stated a rectal tube was inserted without difficulty, the patient tolerated the procedure, there was liquid stool coming through the tubing, and 45 milliters of water was infused into the balloon that held the tube in place in the rectum.


Further review of the clinical record revealed a nursing flow sheet for the morning of 01/06/10 that stated the patient still had the rectal tube in place.

The clinical record review revealed a discharge summary dictated on 01/12/10 that stated the patient's "blood pressure dropped significantly on pressors and also multiple fluid boluses." The discharge summary stated the patient was transferred to another local facility for continuous hemodialysis "as he/she went into acute renal failure." The discharge summary made no mention of the patient's colon being ruptured.

Review of the facility's policy on insertion of a rectal tube, entitled "Flexi-seal Fecal Management System, Insertion of," and approved on 09/14/07, stated a physician's order was necessary before placing the tube. The policy stated to inflate the balloon that held the tube in place in the rectum with 45 milliters of water and to document, among other things, the "position of the indicator line relative to patients (sic) anus."

On 05/04/10 at 4:20 P.M. in an interview, Staff B and C confirmed the nurse did not indicate where the position of the rectal tube's indicator line was relative to the patient's anus.

The clinical record review revealed a nursing care plan dated 12/30/09 (and updated on 01/05/10 and on 01/06/10) that stated the patient had potential for impaired skin integrity related to decreased mobility. The care plan directed the nursing staff to change the patient's position every two hours and as needed, and to document any sign of impending breakdown.


An assessment dated 01/02/10 stated the patient was able to make slight changes in body position, but unable to make frequent or significant changes independently. The clinical record review revealed a nursing flow sheet for 01/02/10 that revealed between 6:00 P.M. and 6:00 A.M. (on 01/03/10) the patient had not been turned.


The clinical record review revealed an assessment dated 01/04/10 that stated the patient was able to make slight changes in body position, but unable to make frequent or significant changes independently. The clinical record review revealed a nursing flow sheet for 01/04/10 that revealed in the early morning of 01/05/10 between 2:00 A.M. and 6:00 A.M. (on 01/05/10) the patient had not been turned.

The clinical record review revealed an assessment dated 01/05/10 that stated the patient was able to make slight changes in body position, but unable to make frequent or significant changes independently. The clinical record review revealed a nursing flow sheet dated 01/05/10 for the hours 7:00 A.M. to 7:00 P.M. that stated the patient's coccyx was reddened, but the skin overall was intact. Neither the nursing flow sheet nor the nursing notes indicated a staging of the reddened area, or its dimensions. The flow sheet did not indicate where the patient had been turned between the hours of 12:00 P.M. and 6:00 A.M. (on 01/06/10). The flow sheet for the time period between 7:00 P.M. and 7:00 A.M. did not indicate whether the patient's skin was intact.

The clinical record review revealed a nursing flow sheet for 01/06/10 that did not indicate whether the patient's skin was intact.

A review of the facility's policy entitled "Skin Assessment and Maintenance of Skin Integrity," approved on 09/14/07, stated a skin assessment is to be performed upon admission and every 12 hours. The policy stated the skin assessment included skin integrity.

A review of the facility's policy entitled "Wound Documentation," approved on 09/14/07, stated wounds are to be staged and measured with accurate length, width, and depth.

On 05/04/10 at 4:20 P.M. in an interview with Staff B and C, both confirmed the lack of turning for Patient #3. Both also confirmed the redness to the coccyx, and the lack of staging and measuring therein.

The clinical record review revealed a graphic/intake/output record dated 01/01/10 that stated the patient had three stools between 07:00 A.M. and 7:00 P.M. and two stools between 7:00 P.M. and 7:00 A.M. The clinical record review revealed an undated nursing flow sheet (later learned through interview with Staff C on 05/04/10, to be that of 01/01/10) that stated the patient was incontinent of liquid brown stool. The flow sheet did not indicate where incontinence care was given.

The clinical record review revealed a graphic/intake/output record dated 01/03/10 that stated the patient had three stools between 07:00 A.M. and 7:00 P.M. The clinical record review revealed a nursing flow sheet dated 01/03/10 that stated the patient was incontinent stool. The flow sheet indicated the patient was provided with incontinence care once at 8:30 A.M. It did not indicate where incontinence care was given at any other time between 07:00 A.M. and 7:00 P.M.

The clinical record review revealed a graphic/intake/output record dated 01/04/10 that stated the patient had two stools between 7:00 P.M. and 7:00 A.M. The clinical record review revealed a nursing flow sheet dated 01/04/10 that did not indicate where any incontinence care was provided between 7:00 P.M. and 7:00 A.M.

On 05/04/10 at 4:20 P.M. in an interview with Staff B and C both confirmed the lack of evidence in the provision of incontinence care.

This finding substantiates complaint #OH00053929.