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On the day of the Complaint survey based on interviews, record reviews, and review of hospital policies and procedures, the hospital failed to ensure that nursing and other personnel provided nursing care and followed physician orders for all patients with identified decubitus as needed for three of five patient records reviewed in which wound care was not documented, turning was not documented, and wound site was not documented . (Patient #1, 4, and 5)

The findings included:

On 2/16/09 at 1345, a review of Patient #1's medical record revealed the sixty-six year old was transferred to the hospital on 6/12/2009 from an acute care inpatient stay preceded by a motorcycle accident which occurred on May 07, 2009.
The patient was admitted on 6/12/2009 to Kindred Hospital following an acute in-patient hospitalization. Extensive injuries sustained included right femur fracture, left open tibial fracture, right patellar fracture, a right closed metacarpal base fracture, and a right clavicular fracture. Past medical history included laryngeal cancer, prior laryngectomy, and chronic tracheostomy approximately five year ago, hypertension, and hypothyroidism. Chest x-rays, on the day of admission revealed a right pleural effusion and evidence of pulmonary edema.
Patient #1 was diagnosed with ventilator dependent pneumonia and a urinary tract infection during the acute hospitalization. A PEG (percutaneous endoscopic gastrostomy) tube was placed on May 14, 2009 for feedings but required temporary cessation of feedings due to the development of an ileus. Orthopedic surgery was performed on May 14, 2009 for fixation of the tibial fracture and closed reduction of the patellar fracture. Progressive stretching of the lower extremity with a CPM (continuous passive motion) machine was recommended.
Due to the manifestation of diarrhea, a fecal management system was initiated. Nursing notes on 6/13/09 showed staff documented generalized edema and no integumentary variances.
The patient's supplemental flowsheet dated 6/15/09 showed staff did not document turning from 2200 through 0600. The patient's flowsheet noted that the CPM was in place at 0800, 0900, 1000, 1100, 1200, 1600, 2000, 2100, 2300, 0100, 0300, and 0500. Nursing notes, dated 6/16/09 showed staff documented 2+ pitting edema of the right lower extremity, vent dependent at 98%. CPM was in progress during the time period 1500 until 2100. The patient's supplemental flowsheet showed staff documented every two hour turning even though documentation showed the CPM was in place.
The "24 Hour Patient Record" dated 6/17/09 showed staff documented that a barrier cream to buttocks was applied at 2130 in the wound care section on the form but did not describe the condition of the skin. Nursing notes showed staff documented a CPM was in progress 1500 through 2130. The supplemental flowsheet showed staff documented patient turning at 0800, and then every two hours from 1200 through 0600 although documentation showed the CPM was in progress.
The "24 Hour Patient Record" dated 6/18/09 showed staff documented, "Barrier cream prn- gluteal" with no time documented but staff initials had been placed in the initials column in the wound care section on the form. Nursing notes showed staff documented a CPM machine in place at 1800. The supplemental flow sheet showed staff documented consistent every two hours turning although the CPM was documented in place from 1900 through 0100.
The "24 Hour Patient Record" dated 6/22/09 showed staff did not include an assessment of the oral cavity which was ordered to be documented every 24 hours as per instructions on the form. A barrier cream to the buttocks was applied at 2100 as noted in the wound care section on the form. There was no documentation of a system review until 2030 and no documentation of any nursing notes until 2030. Nursing notes at 2030 showed staff documented "vent dependent, FMS intact, scrotum edematous, 2 + pitting edema right lower extremity including buttocks and lower flank". On the patient's supplemental flowsheet, turning was documented at 0800 and 1000, and from 2000 through 0600. The CPM was initialed on the flowsheet at 2000.
On 6/23/09, staff documented that a Comfeel dressing was applied to the left and right buttocks at 0800. "Air mattress" was written in on the same form. The Braden scale score was 13 which indicated a moderate risk for pressure ulcers. Per instructions on the form, the Braden Scale scoring was to be completed every Tuesday. A score of 13-14 was moderate risk with a turning schedule to be implemented, foam wedge for lateral positioning, pressure reduction support, and maximal mobilization . Variance notes at 2000 showed staff documented the CPM was in place and Comfeel to buttocks was intact. It was not documented at what time the CPM was discontinued although the supplemental flowsheet showed staff documented every two hour turning throughout the 24 hours.
The "24 Hour Patient Record" dated 6/24/09 showed staff documented "Left and right Comfeel intact" at 0800 in the wound care section of the form. Nursing variance notes showed staff documented Comfeel to buttocks at 0915 but there was no description of the patient's skin. Nurse Notes at 1910 showed staff documented the Comfeel dressing was intact to the patient's sacrum but there was no description of the skin. Hourly turning was documented on the supplemental flowsheet although documentation showed a CPM was in progress from 1800 through 2400.
The "24 Hour Patient Record" dated 6/25/09 showed staff documented "Left and right Comfeel dressing clean/ dry/ intact" at 1000 in the wound care section on the form. The CPM was documented by staff as in progress from 2030 through 0200. The patient's supplemental flowsheet showed staff documented every two hour turning from 0800 through 1800.
The "24 Hour Patient Record" dated 6/28/09 showed staff documented "Sacral dressing changed 1400 and at 0400". The patient's supplemental flowsheet showed staff documented every two hour turning throughout the 24 hour period although variance notes showed staff documented a CPM in progress from 1800 through 2400.
On 6/29/09, a physician progress notes showed a new sacral decubitus ulcer. Physician orders included a Rite Hite bed and a wound consult regarding the sacral unstageable decubitus. The wound consult as documented by the physician on 6/29/09 showed a sacral wound measuring 10.5 x 9.0 centimeters (cm.). Documentation showed the central portion of the wound had an area of eschar measured 7 x 5.5 cm., no purulent drainage, and no bony exposure. The wound was debrided. Wound care orders included: cell mist three times per week, TenderWet dressing cover with foam to be changed daily, turn and reposition and document.
On 6/30/09, a sacral dressing change was documented at 2300 under the wound care section on the "24 Hour Patient Record" with no description of the wound recorded. Turning was documented every two hours. The Braden Scale score was 13 indicating moderate risk.
On 7/1/09, the physician ordered Lenard boots. There was no documentation of the Lenard boots being placed on the patient until 7/9/09.
On 7/1/09, a sacral dressing change was documented at 1300 by the physician. A dressing change time at 0350 was documented by the nurse under the wound care section on the "24 Hour Patient Record" with no additional documentation noted regarding the wound.
On 7/2/09 at 2300, the sacral dressing time change was noted under the wound care section on the "24 Hour Patient Record" but no additional comments regarding the wound were noted.
On 7/3/09, a sacral dressing change was not documented under the wound care section on the "24 Hour Patient Record" or in the nursing variance notes. Every two hour turning was not documented from 2000 through 0600. There was no documentation regarding the CPM.
On 7/4/09, a sacral dressing change was not documented under the wound care section on the "24 Hour Patient Record" or in the nursing variance notes. Turning was not documented from 2200 through 2400.
On 7/5/09, a sacral dressing change time was noted at 0200 under the wound care section on the "24 Hour Patient Record" with no additional documentation regarding the wound. There was no documentation of every two hour turning from 1000 through 2000.
On 7/6/09, the sacral wound was debrided with recorded measurements of 6.2 x 9.6 x 1.2 cm. The stage IV sacral decubitus ulceration involved the right and left sacral areas in the midline with no bony exposure noted. Wound care orders were changed to: "Sacrum cell mist three times per week, TenderWet with foam every twelve hours at 1000 and 2200, dressing must be changed as close to 10:00 A/ 2200 as possible. Patient must be turned and repositioned every two hours and documented". On 7/6/09, a sacral wound dressing change was documented at 2100 under the wound care section on the "24 Hour Patient Record" with no additional documentation regarding the wound provided.
On 7/7/09, sacrum wound care time change was documented at 1000 and 2100 under the wound care section on the "24 Hour Patient Record" with no additional documentation regarding the wound provided. The Braden Scale score was 14 indicating moderate risk for pressure sores.
On 7/8/09, a sacral dressing change time was noted at 0830 under the wound care section on the "24 Hour Patient Record" with no additional comments or dressing changes documented.
On 7/9/09, sacral dressing time changes at 1300 and 0200 were documented under the wound care section on the "24 Hour Patient Record", but no additional comments regarding the wound were noted.
On 7/10/09, the physician ordered the "CPM machine to be placed on the patient from 8-11 AM and 2-5 PM per PT (Physical therapy), need to have on six hours per day and allow for tube feeding schedule. On 2/17/10 at 1630, the Nurse Manager reported that the patient must lie flat when the CPM is in use which prohibits patient turning and tube feedings as the head of the bed needs to be elevated. On 7/10/09, sacral dressing time changes were noted at 0930 and 0015 under the wound care section on the "24 Hour Patient Record", but no additional comments were documented.
On 7/13/09, documentation showed the wound was debrided and measured 7.8 x. 9.5 x 1.6 cm in size with approximately 20% granulation tissue, no purulent drainage, and no bony exposure. Wound care orders remained unchanged.
On 7/14/09, the Braden scale score was 12 indicating the patient was at high risk for pressure sores. Sacral dressing time changes were noted at 1400 and 0013 under the wound care section on the "24 Hour Patient Record" with no additional comments regarding the wound. Nursing variance notes at 0700, read, "... Skin WNL (within normal limits)".
On 7/15/09, sacral dressing changes were documented at 1000 and 2245 under the wound care section on the "24 Hour Patient Record" with no additional comments documented. Every two hour turning was not documented from 1000 through 2000.
On 7/18/09, sacral dressing changes were noted at 1000 and 0400 under the wound care section on the "24 Hour Patient Record". There was no documentation of every two hour turning from 1600 through 2000.
On 7/19/09, sacral dressing changes were noted at 0800 and 0245 under the wound care section on the "24 Hour Patient Record".
On 7/20/09, the sacral decubitus was debrided and measured 7.8 x 11.2 x 1.0 cm in size with approximately 40% granulation tissue, no bony exposure, no periosteal exposure, no tunneling, or undermining. Wound care orders on 7/20/09 were changed to Clorpactin with wound gel moistened 4 x 4's, cover with foam, change every 8 (hours) / prn (as needed) due at 1000 A / 1800 / 0200.
On 7/20/09, sacral dressing changes post debridement were noted at 1830 and 0300 under the wound care section on the "24 Hour Patient Record".
On 7/21/09, the Braden scale score was 14 indicating moderate risk for pressure sores. Sacral dressing changes were documented at 1000, 1800, and 0200 under the wound care section on the "24 Hour Patient Record" with no description of the wound noted. There was no documentation of turning from 0700 until 2000.
On 7/22/09, sacral dressing change times were documented at 1030 and 0200 under the wound care section on the "24 Hour Patient Record". There was no documentation of wound care at 1800.
On 7/23/09, there was no documentation of a systems review until 2100 and no nursing variance notes documented until 2100. Every two hour turning was not documented from 1500 until 2000.
On 7/24/09, sacral dressing change times were documented at 1015 and 0200 under the wound care section on the "24 Hour Patient Record". There was no documentation of wound care at 1800.
On 7/25/09, sacral dressing change times were documented at 1700 and 0200 under the wound care section on the "24 Hour Patient Record" but no description of the wound. There was no documentation of wound care at 1000. Every two hour turning was not documented from 1600 until 2000.
On 7/26/09, sacral dressing change times were documented at 1000, 1600, and 0130 under the wound care section on the "24 Hour Patient Record" but no wound description. Every two hour turning was not documented from 0700 until 1000, from 1000 until 1400, and from 1600 until 2000.
The wound was again debrided on 7/27/09 and measured 7 x 11.4 x 1.1 cm. in size with 50% granulation and 50% of the wound base was necrotic subcutaneous tissue. Wound care orders were changed to discontinue the Clorpactin, perform water debridement 3 x per week, KCI wound vac at 125 mmHg (millimeters mercury) continuous suction, Comfeel to peri-wound/ silver foam change Monday, Wednesday, Friday and as needed.
On 7/29/09, nursing variance notes showed turning and repositioning at 0930. On the supplemental flowsheet, every two hour turning was not documented from 0800 until 1300 and no documentation of turning after 1300.

On 2/17/10 at 1230, a review of Patient #4's medical record revealed the seventy-one year was old admitted on 9/29/09 with diagnoses of chronic respiratory failure with history of bilateral lung transplantation, renal failure, history of diabetes mellitus, and weakness and wasting. Physician progress notes dated 2/9/10 showed anemia with transfusion and a rise in hemoglobin, chronic anticoagulation, trach site okay, and sacral wound. Physician orders dated 2/2/10 and 2/9/10 included orders for wound care instructions for sacral and wrist wounds. Review of nursing notes dated 2/13/10 showed the patient remained on the ventilator, tube feedings via PEG tube, Foley catheter, Perma catheter, and Rite Hite bed. The "Supplemental Flowsheet" dated 2/13/10 did not show staff documented every two hour turning. Turning was documented at 1000, 1500, 1800, and 2400 only.

On 2/17/10 at 1315, a review of Patient #5's medical record revealed the sixty-seven year old was admitted on 1/19/10 with diagnoses of right AKA (above knee amputation) due to infection, stable congestive heart failure, diabetes mellitus with sliding scale on oral medication, DVT (deep vein thrombosis) prophylaxis, and history or MI (myocardial infarction). The initial physical exam included left foot mid-breakdown. Physician orders dated 1/19/10 included wound care orders. A wound care procedure note dated 2/8/10 showed negative pressure wound therapy to an open surgical wound of the right above knee amputation site with VAC (Vacuum Assisted Closure) with dressing change every Monday, Wednesday, and Friday, continue Mepilex Border dressing to the healed wound of the left foot, and foam heel-lift foot protector at all times, and continued antibiotic therapy for chronic osteomyelitis of the right femur. The patient's "Supplemental Flowsheet" dated 2/12/10 showed staff did not document every two hour turning from 0700 until 1800.
On 2/17/10 at 1600, the findings were reviewed and confirmed with the Nurse Manager.

Review of hospital Policy H-ML 10-1014, "Interdisciplinary Care Conference", revised 07/2009, read, "... Policy Statement: An IDT (Inter-disciplinary Team) meets within seven (7) calendar days of a patient's admission and at a minimum weekly thereafter. The team identifies and prioritizes patient's clinical and educational needs, expectations and outcome goals. The identified patient goals are summarized and prioritized by the team ... Procedure: I. Interdisciplinary Care Conference Team Members and Roles: ... Goal Prioritization: Each discipline identifies discipline specific goals...Each discipline is responsible to update the Patient Care Plan as appropriate".

Review of hospital Policy # H-PC 04-009, "Assessment/ Reassessment- Interdisciplinary Patient", revised 5/2009, read, "... Nursing Department: ...5. Patients are reassessed at a minimum every shift-based on level of care and needs by a licensed nurse....Using the reassessment, the RN (Registered Nurse) responsible for the patient, updates the patient's needs/problems and plan of care ... ".

On the day of the Complaint survey based on interviews, record reviews, and review of hospital policies and procedures, the hospital failed to ensure that nursing staff developed and maintained a current individualized nursing care plan for five of five patient records reviewed. (Patient #1, 2, 3, 4, and 5)

The findings included:

On 2/16/09 at 1345, a review of Patient #1's medical record revealed a sixty-six year old admitted on 6/12/2009 following a motorcycle accident May 07, 2009. The patient was admitted on 6/12/2009 to Kindred Hospital following an acute in-patient hospitalization. Extensive injuries sustained included right femur fracture, left open tibial fracture, right patellar fracture, a right closed metacarpal base fracture, and a right clavicular fracture. Past medical history included laryngeal cancer, prior laryngectomy and chronic tracheostomy approximately five year ago, hypertension, and hypothyroidism. Chest x-rays, on the day of admission revealed a right pleural effusion and evidence of pulmonary edema. Patient #1 was diagnosed with ventilator dependent pneumonia and a urinary tract infection during the acute hospitalization. A PEG (percutaneous endoscopic gastrostomy) tube was placed on May 14, 2009 for feedings but required temporary cessation of feedings due to the development of an ileus. Orthopedic surgery was performed on May 14, 2009 for fixation of the tibial fracture and closed reduction of the patellar fracture. Progressive stretching of the lower extremity with CPM (continuous positive motion) machine was recommended. Due to the manifestation of diarrhea, a fecal management system was initiated. Patient #1 was essentially non-verbal with a long standing hearing deficit. A "Team Conference Attendance" sheet with staff signatures dated 6/16/09, 6/23/09, 6/30/09, 7/7/09, and 7/14/09 were found in the chart but no accompanying care plans. A "Patient Care Conference Interdisciplinary Record" was found in the chart dated 7/21/09. Noted under the problem list column on the pre-printed form was Medically Complex which was not completed; "Pain: Alteration in Comfort" which was not completed; "Restraint/Safety/Fall"
which was not completed; "Infection" which was not completed; "Respiratory" with a goal and intervention identified; and "Wound: Alteration in skin integrity" with decreased eschar written in as a goal, no projected goal date or interventions were identified. A "Patient Care Conference Interdisciplinary Record" was found in the chart dated 7/28/09. Problems, goals, and interventions were identified but no projected goal dates were noted.

On 2/17/10 at 1030, review of Patient #2's medical record revealed a sixty-seven year old admitted on 8/28/09 with diagnoses of tracheostomy dependent respiratory failure, anticoagulation requiring heparin infusion, and end stage renal disease. Review of physician progress notes dated 2/8/10 revealed MRSA (methicillin-resistant Staphylococcus aureus) bacteremia/leucocytosis with antibiotic therapy, superficial PEG (percutaneous endoscopic gastrostomy), Stage IV sacral ulcer, diarrhea, conjunctivitis, debility and conjunctivitis. Physician orders dated 2/2/10, 2/9/10 and 2/16/10 included orders for sacral wound care. Physician orders dated 2/17/10 included orders for SCDs (sequential compression device) for both legs. The most current Interdisciplinary Care Conference Record, dated 2/9/10 did not include any documentation in the pre-printed section for infection control prevention. In the Nursing section on the care plan form, code status was not marked. In the section for "Updated/Status and Interventions", WBC (white blood cell) was noted to be 12.05, hemoglobin/hematocrit 9.2/31.6, electrolytes potassium 5.3 and chloride 94. An "X" was written in the box for dialysis, fall risk, and pain managed. In the section for "Short Term Goals and Recommendations", no goals were identified. There was no documentation in the section for "Infection Prevention and Control". In the section for "Wound Care", "deterrents to wound healing, inadequate nutrition intake, and medications were marked in the "Wound Care" section in the "Department" column on the form. Short term wound care goals included "improve wound condition, maintain skin integrity, re-evaluate after debridement, and eliminate infection". The projected goal date was "upon discharge". The "Summary Section for Prioritization of Goals" was blank. The form was signed by members of the interdisciplinary team.

On 2/17/10 at 1115, review of Patient #3's medical record revealed a thirty-three year old admitted on 10/20/09 with diagnoses of ventilator respiratory failure, morbid obesity, sleep apnea, and hypertension. It was noted that the patient has weakness of the right upper and lower extremity, left lower extremity, but has range of motion and movement of the left upper extremity. The Nurse Manager reported in an interview on 2/17/10 at 1625, that the patient has a sacral decubitus and requires total assistance due to the extreme limited mobility. The most current "Interdisciplinary Care Conference Record" dated 2/9/10 showed staff documented the presence of three pressure ulcers in the "Wound Care Section" on the form with intervention of dressing changes every twelve hours, support/specialty bed, and turn and reposition every two hours. Wound care goals included to improve wound condition, maintain skin integrity, and eliminate infection. The projected goal date was "upon discharge". The "Nursing" department section on the form was blank. The "Summary Section for Prioritization of Goals" was blank. The form was signed by members of the interdisciplinary team.

On 2/17/10 at 1230, review of Patient #4's medical record revealed a seventy-one year old admitted on 9/29/09 with diagnoses of chronic respiratory failure with history of bilateral lung transplantation, renal failure, history of diabetes mellitus, and weakness and wasting. Physician progress notes, dated 2/9/10, anemia with transfusion and rise in hemoglobin, chronic anticoagulation, trach site okay, and sacral wound. Physician orders dated 2/2/10 and 2/9/10 included orders for wound care instructions for sacral and wrist wounds. Review of nursing notes dated 2/13/10 showed the patient remained on the ventilator, tube feedings via PEG tube, Foley catheter, Perma catheter, and Rite Hite bed. The most current "Interdisciplinary Care Conference Record" dated 2/9/10 showed staff documented one pressure ulcer, improved. Interventions included fecal management sytem, support surface/specialty without type noted, debridement was marked on the form with recommended excisional and non-excisional with both performed in the past seven days, and turn every two hours. Documented under the section for "Short Term Goals and Recommendations" were to improve wound healing, maintain skin integrity, re-valuate after debridement, and eliminate infection. The projected goal date was "upon discharge". In the section for "Infection Control Prevention", it was noted that there was no MDRO (multi-drug resistant organism) and "Foley" was marked in response to "Meets criteria for:" There was no documentation for precautions. There were no interventions noted. Short term goals and recommendations included to prevent infection. There was no projected goal date. Documented in the section for "Nursing" was WBC 8.2, hemoglobin 8.2, hematocrit 30.10, sodium 132, potassium 3.4, chloride 95, glucose level 80 to 223, and abnormal test result included BUN (blood urea nitrogen) 40. Dialysis, fall risk, sedative medications of Ativan for anxiety/agitation, blood products/reason was anemia, pain managed, and telemetry were marked, and change in condition was noted as wasting with admission weight of 55.4 Kg., and current weight of 50.1. There were no goals identified. The "Summary Section for Prioritization of Goals" was blank. The form was failure, signed by members of the interdisciplinary team. The "Supplemental Flowsheet" dated 2/13/10 showed staff did not document every two hour turning. Turning was documented at 1000, 1500, 1800, and 2400.

On 2/17/10 at 1315, review of Patient #5's medical record revealed a sixty-seven year old admitted on 1/19/10 with diagnoses of right AKA (above knee amputation) due to infection, stable congestive heart failure, diabetes mellitus with sliding scale on oral medication, DVT (deep vein thrombosis) prophylaxis, and history or MI (myocardial infarction). The initial physical exam included left foot mid-breakdown. Physician orders dated 1/19/10 included wound care orders. A wound care procedure note dated 2/8/10 noted negative pressure wound therapy to an open surgical wound of the right above knee amputation site with VAC (Vacuum Assisted Closure) with dressing change every Monday, Wednesday, and Friday, continue Mepilex Border dressing to the healed wound of the left foot and foam heel-lift foot protector at all times. Continued antibiotic therapy for chronic osteomyelitis of the right femur.
The most current "Interdisciplinary Care Conference Record" dated 2/9/10 showed staff failed to document identified problems under the section for wound care. It was noted that the patient had one surgical wound. Negative pressure therapy was noted as the intervention. It was not noted that the patient had debridement performed on 2/8/10 with dressing changes ordered. Under the section for "Infection Prevention and Control", the patient was on contact precautions due to final cultures dated 12/3/09 and 1/22/10 were positive for VRE (Vancomycin- resistant Enterococci). Short term goals and recommendations included to resolve VRE infection, prevent infection and patient/family education regarding contact precautions. There was no projected goal date. Under the "Nursing" section, code status was not documented. Electrolytes were within normal limits, a PICC (peripherally inserted central catheter) was in place, fall risk was indicated due to generalized weakness and right AKA wound VAC. It was noted that pain was managed and the patient was on telemetry. There were no goals identified. The "Summary Section for Prioritization of Goals" was blank. The form was signed by members of the interdisciplinary team. On the "Interdisciplinary Care Conference Record" dated 2/2/10 and 1/26/10, the "Nursing" section was blank. The "Supplemental Flowsheet" dated 2/12/10 showed staff did not document every two hour turning from 0700 until 1800. Turning was documented from 1800 through 0600.
On 2/17/10 at 1600, the findings were reviewed and confirmed with the Nurse Manager.

Review of hospital Policy H-ML 10-1014, "Interdisciplinary Care Conference", revised 07/2009, read, "... Policy Statement: An IDT (Inter-disciplinary Team) meets within seven (7) calendar days of a patient's admission and at a minimum weekly thereafter. The team identifies and prioritizes patient's clinical and educational needs, expectations and outcome goals. The identified patient goals are summarized and prioritized by the team ... Procedure: I. Interdisciplinary Care Conference Team Members and Roles: ... Goal Prioritization: Each discipline identifies discipline specific goals...Each discipline is responsible to update the Patient Care Plan as appropriate".

Review of hospital Policy # H-PC 04-009, "Assessment/ Reassessment- Interdisciplinary Patient", revised 5/2009, read, "... Nursing Department: ...5. Patients are reassessed at a minimum every shift-based on level of care and needs by a licensed nurse....Using the reassessment, the RN (Registered Nurse) responsible for the patient, updates the patient's needs/problems and plan of care ... ".