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Based on review of documentation and interviews with staff, the facility failed to ensure the registered nurses supervised and evaluated the nursing care for patients #1 and #2.

Findings included:

During a review of the medical record for patient #1 the following was revealed:

1. The patient was a 62 year old who was admitted to Mesquite Specialty Hospital on 8/24/2012. Patient #1 was still a patient at the time of the survey. Review of the History & Physical (H&P) revealed a history of Hypertension, Diabetes, Pancreatitis, Restless Leg Syndrome, Methicillin-Resistant Staphylococcus Bacteremia, and Hyperlipidemia. The chief complaint on admission was "Infected right hip prosthesis, status post removal of the prosthesis and Bacteremia." The H&P stated the patient "came in for continuation of her antibiotics and wound care of her right infected hip."

2. Review of admission orders dated 8/24/2012, revealed the wound care team was to evaluate the patient's non-healing wound. The Attending Physician signed the Admission orders. There was no documentation in the medical record the wound care team assessed the patient.

3. Review of Nutritional Assessment documentation dated 8/27/2012 at 2:46pm stated the patient had a recent history of weight loss for unknown reasons. The documentation revealed her current weight was 164.5 lbs. The Dietitian documented in plan of care the staff was to monitor the patient's intake, weight, and wound care. The Interim Unit Manager stated in an interview on 9/25/2012 at 3:35pm, that the patients are weighed weekly. The Interim Unit Manager stated some patients were weighed more frequently depending on their condition.

4. Review of Physician's Order dated 9/1/2012 revealed "Fluid restriction to 1500cc/day." In interviews with staff members #1, #4, #5, and #6 the afternoon/evening of 9/25/2012, it was stated that patients on fluid restrictions have daily weights. It was a nursing judgment. The nurses stated if a physician wrote an order for fluid restrictions then the physicians were ordering strict intake and output. The nurses stated that patients on strict intake and output have daily weights. Staff member #1 stated the afternoon of 9/25/2012, " that ' s how you know it ' s effective or not. "

5. Review of the patient's "Daily Flow sheet Treatment Record" revealed that 12 of the 23 days the patient was on a fluid restriction, the nurses failed to follow the physician's order. The physician ordered for the patient to have up to 1500 cc of fluid a day.

6. Further review of the patient's "Daily Flow sheet Treatment Record" revealed on 9/2/2012 patient #1 ' s intake was 2118 cc/day, on 9/11/2012 the intake was 2350 cc/day, on 9/16/2012 the intake was 2020 cc/day, and on 9/20/2012 the intake was 1920 cc/day.

7. Review of the patient ' s graphic sheet revealed that patient #1 weighed 164.5 pounds on 9/1/2012. The patient was reweighed on 9/2/2012 which stated 164 lbs. On 9/7/2012, the document revealed a weight of 189 lbs. This was a weight gain of approximately 25 lbs. There was no documentation the staff member reweighed the patient or notified the nurse. On 9/8/2012 the documented weight was 189 lbs. There was no documentation the staff member reweighed the patient or notified the nurse. The next documented weight was on 9/16/2012 which revealed a weight of 80.5 kg (approximately 177 pounds). This was a weight loss of approximately 12 pounds. There was no documentation the staff member reweighed the patient or notified the nurse. There was no other weight's documented in the copies of the medical records provided to the surveyor. The nurses failed to monitor Patient #1 ' s weight.

During a review of the medical record for patient #2, revealed the following:

1. The patient was a 73 year old admitted to Mesquite Specialty Hospital on 9/2/2012. The patient was still a patient at the time of the survey. Review of the History & Physical (H&P) revealed the patient had a history of a Stroke, Diabetes, Dyslipidemia, Dementia, and Congestive Heart Failure. The chief complaint was sacral decubitus ulcer which was infected and the patient was non-verbal. The H&P also stated the patient had persistent leukocytosis, Methicillin-Resistant Staphylococcus Epidermis (MRSE) Bacteremia. The plan was for IV antibiotics, monitor blood sugar levels, blood pressure, heparin, Coumadin, and wound care. The Nursing Admission Assessment dated 9/2/2012 revealed the patient had a Stage II sacral pressure ulcer and the Attending Physician ordered for an evaluation of the wound by the wound care team.

2. Review of Nutritional Assessment dated 9/2/2012 stated Patient #2 ' s current weight was 150.7 pounds. The Dietitian noted Patient #2 ' s intake was less than 25%. The plan was to monitor Patient #2 ' s tolerance to diet, meals, and supplements. Also noted was to monitor intake, weights, labs, and wound care. There was no documentation of how often to monitor the patient ' s weight.

3. Review of Facility document entitled "Interdisciplinary Physician Led Plan of Care" revealed on 9/2/2012, the nurse noted in the "Alteration in Skin Integrity" section, "Coccyx: 6cm x 8 cm; R (right) Elbow 2 cm x 1 cm; Pressure relief/positioning; Assessment by wound care team at least weekly. " There was no documentation the wound care team assessed the patient weekly.

4. Facility document entitled "Interdisciplinary Progress Notes" revealed the Dietitian noted on 9/5/2012 at 12:02pm the patient had a Stage II sacral wound and to monitor weight trends. There was no documentation of how often to monitor the weight or that the nursing staff was monitoring the weights.

5. Wound care nurses notes revealed that on 9/11/2012, the interim wound care nurse evaluated Patient #2 ' s wound. Documentation revealed the nurse was unable to stage the wound. The wound care nurse sized the decubitus ulcer as 5cm x 6cm. Review of physician order dated 9/4/2012 stated to "clean the sacral wound with hibiclens and normal saline, apply santyl and maxord every day with bordered gauze." There was no documentation the wound care nurse applied santyl as per physician orders. The facility failed to follow its own policies and procedures.

6. Review of the Interdisciplinary Progress notes revealed on 9/12/2012 at 9:57am, the Dietitian noted "no new weight recorded." She documented Patient #2 ' s intake was 10-25% which was inadequate and to recheck weight frequently. There was documentation of how frequently to recheck the weight.

7. Review of Physician Progress Notes dated 9/17/2012 stated, "Examination of the sacral wound overall appears to be decreasing in dimensions, but the depth has increased with thick necrotic fibrinous tissue almost close to the bone ... " The wound care physician's assessed the wound as sacral decubitus ulcer, probably Stage III-I and severe protein malnutrition secondary to decreased intake. The physician also assessed the wound as infected decubitus ulcer, methicillin-resistant staphylococcus aureus.

8. Review of the Interdisciplinary Progress notes revealed on 9/18/2012 at 2:29pm, the patient weight was 149.4 (weighed on 9/16) and the intake was minimal. The Dietitian documented to recheck weight frequently.

9. Review of facility document entitled "Daily Flow sheet Treatment Record" revealed the patient was not repositioned per physician's order for 20 of 20 days. From dates 9/4/2012 to 9/23/2012, documentation revealed the patient was lying on her back or was not repositioned every 2 hours. Review of physician order dated 9/4/2012 revealed the physician wrote an order to turn the patient every 2 hours and to keep the patient on her sides.

10. Review of the Graphic Sheet revealed the patient's weight on 9/16/2012 was 149.4 pounds. On 9/20 the patient's weight was 173.5 pounds. On 9/22, the patient weighed 179.5 pounds which was approximately 30 pounds in one week. On 9/23 she weighed 160.5 pounds. The nursing staff failed to monitor the patient's weight.

Review of facility document entitled "Admission Assessment & Screen" stated "To provide a standardized method for documentation initiated at the time of inpatient admission at the hospital." The policy stated, "The goal of a patient assessment is to determine the appropriate care, treatment, and services required to meet the patient's initial needs ... The initial assessment and screen may identify the need for additional assessments." Further review revealed, " Procedure: B. Further Assessments: Additional assessments are to be completed based on the results of the physician history and physical and the nursing assessment ... "

Review of the facility document Admission Assessment: Arrival/Entry Data stated the definitions of each Stage of a Pressure Ulcer to assist the nursing staff. The following are the definitions:
a) UnStageable: Full thickness tissue loss in which the baser of ulcer is covered with slough or eschar.
b) Stage I: Non-blanchable erythema of intact skin ...
c) Stage II: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
d) Stage III: Full thickness skin loss involving subcutaneous tissue that may extend down to but not through underlying tissue. Slough may be present but does not obscure the wound. May include tunneling.
e) Stage IV: Full thickness skin loss with extensive destruction, or damage to muscle, bone or supporting surfaces. Slough or eschar me be present on some parts of wound bed but does not obscure the wound. May be tunneling.

Review of facility document entitled "Reassessment" stated "To provide on-going relevant data pertaining to biophysical, psychosocial, environmental, self-care, educational, and discharge needs throughout the continuum of care." The policy stated, "Patients at the hospital receive care based upon a documented assessment of patient care needs and problem identification ... In order to achieve this goal, the following processes are performed: A. Data are collected to identify problems and assess the needs of the patient. B. The data are analyzed to establish the plan of care. C. Decisions are made regarding patient care of treatment, based on analysis of the data. "Further review revealed, "The RN (Registered Nurse) will perform reassessment and will direct patient care through a variety of mechanisms including notification of the change to the physician, change to plan of care, and other interventions based on the patient need."

Review of facility document entitled "Interdisciplinary Wound Prevention Assessment and Treatment" stated "I. Purpose: A. To provide guidelines for the prevention, assessment and treatment of wounds. B. To identify patients at-risk for skin breakdown and pressure ulcer formation."

The facilities definition of a pressure ulcer stated: "D. A pressure ulcer is a localized in injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Further review revealed, "H. An Interdisciplinary wound treatment will recommend via the interdisciplinary care plan the appropriate interventions for the wound(s)." In the section "Plan of Care" revealed, "Based on the identification of the skin integrity issues during assessment and reassessment, the plan of care will include interventions for care."

In the section "Documentation" the policy stated, "P. Photo documentation must be completed on 1st dressing change after admission and weekly and recorded within the medical record. Q. Daily findings will be recorded on the Nursing Flow Sheet. R. The plan of care will be reviewed and revised at least weekly. S. Any identification new or worsened wounds must be documented as above and on a hospital Incident Report form."

In in-person interviews the afternoon of 9/25/2012 with the Facility Compliance Officers, the Interim Unit Manager, and the Interim Director of Nursing Operations, it was confirmed the facility failed to monitor patient weights, physician orders, and provide wound care according to facility policies and procedures.

Based on review of documentation and interviews with staff, the facility failed to ensure that the nursing staff developed and kept current a nursing plan of care for patient #2.

Findings included:

Review of the medical record for patient #2, revealed that the plan of care revealed on 9/18/2012, in the section "Alteration in Nutrition/Hydration," Refusal to eat, Stage III sacral."

The plan of care was not updated in the section "Alteration in Skin Integrity." The medical record revealed that Patient #2's sacral decubitus ulcer on admission was a Stage II and changed to a Stage III-IV. The last documentation on the plan of care for Alteration in Skin Integrity was on 9/2/2012.

Review of Facility document entitled "Interdisciplinary Physician Led Plan of Care" revealed on 9/2/2012, the nurse noted in the section "Alteration in Skin Integrity; Coccyx: 6cm x 8 cm; R (right) Elbow 2 cm x 1 cm ...Assessment by wound care team at least weekly."

Review of facility document entitled "Reassessment" stated, "Patients at the hospital receive care based upon a documented assessment of patient care needs and problem identification... In order to achieve this goal, the following processes are performed: A. Data are collected to identify problems and assess the needs of the patient. B. The data are analyzed to establish the plan of care. C. Decisions are made regarding patient care of treatment, based on analysis of the data. "Further review revealed, "The RN (Registered Nurse) will perform reassessment and will direct patient care through a variety of mechanisms including notification of the change to the physician, change to plan of care, and other interventions based on the patient need."

In in-person interviews the afternoon of 9/25/2012 with the Facility Compliance Officers, the Interim Unit Manager, and the Interim Director of Nursing Operations, it was confirmed the facility failed to keep current the plan of care for patient #2.