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Based on record review and interview the facility failed to provide Patient # 2 with a copy of her Patient Rights upon admission per the facility policy. The facility census was 66.

Findings included:

Record review of Patient #2's medical record revealed the patient had been admitted to the facility on 3/19/10 for treatment of cellulitis ( a common skin infection caused by bacteria) and ulcerations (an open sore) to both lower extremities (legs).

-Record review of the Nursing Admission Assessment dated 3/19/10 in part revealed the following:
Neurological assessment:
Orientation to time/place:
Patient is independently oriented to person, place and time.
Behavior: alert, cooperative, follows 2 step commands.

Record review of the Admission Document Checklist dated 3/19/10 which is a list of information to be provided by the facility to the patient at admission. This includes 15 items such as Admission Agreement, Patient's Rights and Responsibilities, Advanced Directives, Notice of Privacy Practices, An Important Message from Medicare. No items had been checked by the staff as being completed nor had the copies been provided as demonstrated by no circling of the word copy. The patient's signature was at the bottom of the page with no date.

-Record review of the facility's policy Patient Safety/Risk Management revised on 05/2009 revealed in part the following information:
Procedure
1. The list of Patient Rights and Responsibilities is provided to each patient at admission.
-Record review of the facility's policy Rights and Responsibilities, Patient revised 04/06 in part revealed the following information:
Patient/Family/Surrogate Rights
1. The patient has the right to receive a copy of the document "Patients' Rights and Responsibilities" in advance of patient care being furnished or discontinued whenever possible.

-During an interview on 3/24/10 at 2:30 p.m. Patient #2 stated she had not seen any patient's rights and she did not have a copy of her patient rights and still did not after being in the hospital for four days and she did not have any rights.

During an interview on 3/24/10 at 3:20 p.m. Staff B stated the admission staff completed a checklist and copies were given to the patient at admission. He/she stated if the checks were not present, the patient did not get copies. This would include Admission Agreement, Patient Rights, Advanced Directive and An Important Message from Medicare among the other 15 items listed. He/she stated the form was incomplete.

Based on observation, interview and record review the facility failed to prevent the development of pressure sores for two of three patients reviewed with pressure sores (Patients #6 and #31). The facility also failed to document and measure pressure sores as directed in their policy. The facility census was 66.
Findings Included:
1. Review of a facility policy entitled, " Prevention of Skin Breakdown, " revised 11/2009, revealed the following:
a) Early identification of patients at risk, and implementation of preventive interventions can decrease patients ' morbidity and mortality and increase comfort and general quality of life.
b) Complete and document a visual and tactile assessment of the patient ' s skin during each shift.
c) Avoid positioning on hips.
d) Relieve pressure on heels by raising heels off bed.
Review of Patient #31 ' s History and Physical (H & P) dated 02/03/10 revealed the patient was admitted on 02/02/10 with diagnoses of quadriplegia (paralyzed-makes someone a higher risk for development of pressure sores), and a Stage III pressure sore (full thickness skin loss involving damage to or necrosis [dead tissue] of subcutaneous tissue, presents as a deep crater) on his/her coccyx (tailbone). The patient did not have any pressure sores on his/her hips when admitted.
Review of nurses ' notes dated 03/17/10 revealed the patient had developed a pressure sore on the left hip. The pressure sore was described as 3 centimeters (cm) by 4.5 cm, by 0.1 cm deep, 75% black/necrotic and 25% pink. Facility staff failed to identify and/or document this pressure sore until it was already necrotic.
Review of a physician ' s progress note dated 03/17/10 revealed the patient had a new ulceration to the left hip.
Review of physician ' s orders revealed treatment orders were not received until 03/19/10 at 9:00 p.m., two days after identified.
Review of a physician ' s progress note dated 03/25/10 revealed the pressure sore on the left hip was a Stage III, and worsened.
Review of the patient ' s entire record on 03/26/10 revealed staff failed to document any further measurements or description of the left hip pressure sore. Staff member F confirmed there was no further documentation regarding this pressure sore, and said pressure sores were to be measured weekly and documented per policy.
Observation on 03/26/10 at 9:15 a.m. revealed the patient had a one-half dollar sized Stage III pressure on the left hip. The pressure sore was yellowish/gray with redness surrounding.
2. Review of Patient #6 ' s H & P dated 01/06/10 revealed the patient was admitted on 01/05/10 with diagnoses of a past stroke and respiratory distress, including use of a tracheostomy (a tube in the neck to allow breathing). The patient did not have any pressure sores upon admission.
Review of nurses ' notes from 01/29/10 through 02/23/10 revealed the following:
a) The patient developed pressure sores on the left heel and right ankle on 01/29/10.
b) Measurements were not documented until 02/03/10; left heel 1.5 cm by 1.5 cm, Stage I (persistent redness); right ankle 2.0 cm by 1.5 cm, Stage I
c) On 02/06/10 the patient developed a pressure sore on the left 5th toe measuring 2.0 cm by 1.7 cm and 90% eschar (necrotic). Facility staff failed to identify and document at an earlier stage so deterioration could have been prevented.
d) By 02/06/10 the left heel pressure sore measured 3.0 cm by 3.0 cm and was dark red or purple and/or non-blanchable (indicates poor circulation to the area).
e) On 02/19/10 the left 5th toe was 100% eschar/necrotic. The left heel measured 3.0 cm by 6.0 cm and was 100% eschar. The right ankle was now necrotic and measured the same as on 02/03/10.
Review of a physician consult dated 01/28/10 revealed the patient had eschar on the left heel. The physician said the left heel pressure sore was a Stage III. The physician ordered Prevalon boots (a padded boot used to relieve pressure), after the patient had already developed pressure sores to his/her feet.
Review of the patient's care plan for skin on 03/26/10, initiated 01/06/10, revealed a potential for impaired skin integrity, not actual impaired skin integrity. The goal was that the patient would maintain intact skin and exhibit no signs of redness. Interventions included inspecting the skin during position change and use skin protection to high risk areas. Staff failed to amend the care plan to reflect current pressure sores, new goals, and interventions to cause improvement.
During an interview on 03/25/10 at 3:00 p.m. Registered Nurse staff member E said the wound care nurses see every patient every week to measure wounds. However, they don ' t always document their findings the day they see. Staff member E said there were no further findings regarding Patient #6.
Patient #6 was discharged from the facility on 02/24/10. The receiving facility ' s documentation revealed the patient had Stage IV pressure sores (Full thickness skin loss, tissue necrosis or damage to muscle/bone) on his/her left outer foot near the 5th toe, left heel and right inner ankle.

Based on record review and interview the facility failed to ensure the staff follow the facility policy and initiate and develop an ongoing care plan which assessed the patient's needs and develop appropriate nursing interventions in response to those needs for three Patients #2, #6, and #22 out of five patients reviewed. The facility census was 66.

Findings included:

During an interview on 3/25/10 at 3:05 p.m. the CCO T stated there was no documentation in the care plan which indicates the patient was provided an interpreter, written material or a telephone in order to translate for him.

1. Record review of Patient #2's medical record revealed the patient had been admitted to the facility on 3/19/10 for treatment of cellulitis ( a common skin infection caused by bacteria) and ulcerations (an open sore) to both lower extremities (legs).
-Record review of the patients Nursing Admission Assessment revealed in part the following information:
Chief complaint: bilateral thigh decub ulcers (pressure sores).
-Record review of the Care Plan Dx (diagnosis) dated 3/20/10 revealed in part the following information:
No implementation of interventions or goals for the assessed lower extremity ulcerations were noted.

During an interview on 3/25/10 at 11:00 a.m. the Licensed Practical Nurse (LPN) BB stated the care plan did not include interventions or goals for the assessed wounds.

2. Record review of the medical chart of Patient #22 revealed the patient was admitted to the facility on December 15, 2009 for continuing local wound care and possibly hyperbaric (medical use of oxygen to increase the healing of wounds) oxygen after massive third degree burns on 45% of his body.
-Record review of the History and Physical dated 12/16/09 in part revealed documentation which stated the patient was "a Hispanic Gentleman" and "there is a language barrier".
-Record review of the Nurses Notes on 12/16/09 in part revealed documentation which stated the patient spoke "English only".
-Record review of the Care Plan Diagnosis dated 12/15/09 revealed no identification of Language as being a need of the patient.
-Record review of the patient's Interdisciplinary Care Conference Records dated 12/23/09, 12/30/09, 1/7/10, 1/21/10, 1/28/10, 2/4/10, 2/11/10 and 2/28/10 and signed by some of the Interdisciplinary Team revealed in part the following information:
-On 12/23/09 "language" is identified as Other under Nursing Update/Status and Interventions. No Interventions, Goals and Recommendation or Follow up and Goal Prioritization are listed
-On 2/18/10 Spanish Interpreter as needed is documented under Nursing Goals with no interventions listed
-Record review of the Patient's medical chart revealed no documentation of any interventions used to communicate with this patient other than an Occupational Therapist and an Admitting Clerk both of whom spoke Spanish but worked days only.
-Record review of the patient's Interdisciplinary Care Conference Records dated 12/23/09, 12/30/09, 1/7/10, 1/21/10, 1/28/10, 2/4/10, 2/11/10 and 2/28/10 and signed some by the Interdisciplinary Team revealed in part the following information:
-On 12/23/09 language is identified as Other under Nursing Update/Status and Interventions. No Interventions, Goals and Recommendation or Follow up and Goal Prioritization are listed.
-On 2/18/10 Spanish Interpreter as needed is documented under Nursing Goals with no interventions listed.

Review of policy: Assessment / Reassessment - Multidisciplinary Patient H-PC 04-009 dated 05/09 stated in part: Nursing Service: 5.It is recommended that each patient are reassessed at a minimum every shift by a licensed nurse. An RN reassesses the patient every 24 hours. The assessment(s) are recorded in the patient medical record. Using the reassessment, the RN responsible for the patient, updates the patient's needs/problems and plan of care 7. A collaborative assessment and individualized Patient Care Treatment Plan is discussed with the interdisciplinary team during the Patient Care Conference. Each patient is reviewed within at least seven days of admission and no less than weekly thereafter at the Interdisciplinary Patient Care Conference.

During an interview on 3/25/10 at 3:05 p.m. the CCO T stated there was no documentation in the care plan which indicates the patient was provided an interpreter, written material or a telephone in order to translate for him.





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3. Review of Patient #6's H & P dated 01/06/10 revealed the patient was admitted on 01/05/10 with diagnoses of a past stroke and respiratory distress, including use of a tracheostomy (a tube in the neck to allow breathing).
Review of nurses' notes from 01/29/10 through 02/23/10 revealed the following:
a) The patient developed pressure sores on the left heel and right ankle on 01/29/10.
b) On 02/06/10 the patient developed a pressure sore on the left 5th toe measuring 2.0 centimeters (cm) by 1.7 cm and 90% eschar (necrotic).
d) By 02/06/10 the left heel pressure sore measured 3.0 cm by 3.0 cm and was dark red or purple and/or non-blanchable (indicates poor circulation to the area).
e) On 02/19/10 the left 5th toe was 100% eschar/necrotic. The left heel measured 3.0 cm by 6.0 cm and was 100% eschar. The right ankle was now necrotic and measured the same as on 02/03/10.
Review of a physician consult dated 01/28/10 revealed the patient had eschar on the left heel. The physician said the left heel pressure sore was a Stage III (full thickness skin loss usually presenting as a crater). The physician ordered Prevalon boots (a padded boot used to relieve pressure), after the patient had already developed pressure sores to his/her feet.
Review of the patient's care plan for skin on 03/26/10, initiated 01/06/10, revealed a potential for impaired skin integrity, not actual impaired skin integrity. The goal was that the patient would maintain intact skin and exhibit no signs of redness. Interventions included inspecting the skin during position change and use skin protection to high risk areas. Staff failed to amend the care plan to reflect current pressure sores, new goals, and interventions to cause improvement and prevent further breakdown.