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Based on observation, interview and record review, facility ' s nursing staff failed to develop comprehensive care plan to address pressure sore management in 1 of 2 patients observed with pressure sore from a sample of 33, citing Patient #5.

Finding:

On 06/06/2012 at 9:20 a.m. patient # 5 was observed lying in bed in her room. The patient was unresponsive to verbal stimuli.

Interview on 06/06/2012 at 9:20 a.m. with registered nurse (Z2 ) who was assigned to the patient revealed the patient was on hospice care, has a pressure sore to her coccygeal area which was treated with a cream.

Observation on 05/06/2012 at 9:22 a.m. revealed patient had a stage two pressure sore to her coccygeal area approximately 2 cm X 5 cm. The skin was broken and raw. There was no dressing in place. The patient was observed with a bowel movement at the time of observation.

Review of the patient ' s nursing assessment dated 05/29/2012 revealed a Braden Scale Assessment which revealed the patient did not have a pressure sore to her coccygeal area on admission. The Braden Scale Assessment indicated that the patient was high risk for the development of pressure sore.

Review on 06/06/2012/of the patient ' s clinical record revealed documentation on the nurses ' progress notes that the patient had a stage two pressure sore to the coccygeal area.
Review of the patient ' s record revealed there was no comprehensive care plan to address pressure sore management. There was no order on the patient ' s record to treat the patient ' s pressure sore.

During an interview with the Director of the Unit on 06 /06/2012 at 10:20 a.m. revealed the patient was treated with alovesta barrier cream to her pressure sore.
She then presented the Surveyor with a care plan and physician ' s order for the management of the pressure sore which was dated 06/06/2012. She confirmed that the order for the pressure sore was secured after the Surveyor ' s observation and request for a care plan and physician ' s order to treat the patient ' s pressure sore.

Review of the Hospital Plan for the provision of care # 900-701 directed staff as follows: " A plan of care is developed based on initial and on going assessment of the patient. The plan is interdisciplinary, is developed collaboratively, and is reviewed daily and updated by members of the interdisciplinary team. "

Based on record review and interview the hospital failed to document Utilization Review Committee (UR) meeting minutes in 2011.

Findings include:

Record review of "Utilization Management Committee Meetings" revealed no meeting minutes for 2011. Meetings were documented in 2012 as follows 3/20/12, 4/3/12, and 5/4/12.

The Quality Assurance Director (ID# 51) acknowledged 6/5/12 at 11:45 a.m. the hospital had previously held informal UR meetings in 2011 and recently began form (documented) meetings in 2012.

Record review of a policy titled "Utilization Management / Case Management Plan" dated March 2012 stated "The Utilization Management Committee shall meet as often as necessary to accomplish it's function." The purpose stated "To ensure that the services delivered to the patient's are medically necessary , in the appropriate setting and are appropriate for the diagnosis, condition, or medical problem... The UR Plan was not specific regarding how often the UR Committee would be required to meet.