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Based on facility policy, medical record review, and staff interviews, the facility failed to notify the patient's family of a change in condition in the patient, related to the development and treatment of pressure ulcers.

Findings:-

Review of the facility's policy, #WCIV-1, "Wound Care Initial Plan of Care," effective 06/10/2008, and last revised 04/01/14, revealed that at any time during a patient's stay in the facility, a meeting may be reconvened at the request of the patient and/or family member, or staff, based on changes in condition to answer additional questions.
Review of the facility policy, #P01-A, "Patient Rights," effective 12/01/1998, and last revised 01/01/2010, revealed that the attending physician would inform the patient of his/her medical condition. Per policy, the patient would have the opportunity to participate in the planning of his/her medical treatment.
Review of the facility policy, #WCII-1, "Wound Program Overview and Initiation Process," effective 06/10/2008, and last revised 04/01/2014 revealed that patients and families would be an integral part of the planning phase. In addition, the wound care team would be responsible for the education of clinical staff, patients, and families.
Review of the Wound Documentation Forms revealed that on 08/11/16, a stage II (partial loss of skin with exposed dermis, the thick layer of living tissue below the top layer of skin which contains blood capillaries, nerve endings, sweat glands, hair follicles, and other structures) pressure ulcer was noted on the patient's left lower extremity. The wound measured 5 x 2.4 centimeters. The medical record revealed that on 09/06/16, a stage III (a loss of skin in which fat tissue is visible in the pressure ulcer rolled wound edges are often present) pressure ulcer was observed on the patient's trochanter (left hip area), which measured 5 x 6.3 centimeters. Additionally, an unstageable (skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is obscured by yellow fibrinous tissue and dry crusted skin) pressure ulcer was noted to the patient's right hip on 09/06/16, which measured 7.6 x 7.4 centimeters.

Review of the Wound Documentation sheets revealed that photographs were taken on 09/06/16, and treatment or assessment was documented regarding the bilateral trochanter wounds the patient developed prior to discharge on 09/09/16.
Review of the Daily Nursing Assessment Sheet dated 06/06/16 through 09/09/16 revealed no documentation of the patient's bilateral trochanter (hip area) pressure ulcers.

Further review revealed no documentation in the nurse's notes that the patient's family were notified of a change in condition.

During an interview with the Director of Quality Management (DQM, Staff #7) on 10/24/16 at 11:55 a.m. in the Doctor's Charting Room, the DQM stated that he/she remembered patient #1 because the patient's hospital stay was of longer duration than the average patient stay, which is normally approximately twenty (20) to twenty-five (25) days. The DQM stated that staff members are updated on a change in a patient's condition during the course of the admission when the Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion towards a common goal for the patient) meets every Wednesday. The DQM stated that during that meeting all aspects of the patient's care, changes in condition, and care issues are discussed between the disciplines involved in the patient's care. The DQM added that patient's families are invited to be present during hospital rounds (a series of professional bedside calls on hospital patients made by a doctor, nurse, or other medical staff) on Tuesdays and Thursdays so they can ask any questions regarding the patient's care and condition. The DQM stated that all disciplines are present during the hospital rounds. The DQM stated that patient #1's family should have been notified of the wounds present on the patient's trochanter area.

During an interview with the Chief Nursing Officer (CNO, Staff #4) on 10/24/16 at 1:00 p.m. in the Doctor's Charting Room, he/she stated it is the policy of the facility for the nursing staff to inform the patient's responsible party regarding any change in the patient's condition and to document in the patient's medical record that the family had been so notified.


During an interview with MD#3, (Medical Doctor) on 10/25/16 at 11:30 a.m. in the Doctor's Charting Room, the MD stated that he/she remembered patient #1 due to the length of the patient's admission stay. The MD indicated that he/she assumed care of the patient in late August of this year. The MD recalled speaking with the patient's family regarding the patient's condition. The MD indicated he/she did not remember speaking with the family specifically about the patient's pressure ulcers. The MD explained that he/she normally would not call a patient's responsible party regarding a pressure ulcer unless the pressure ulcer had risen to a level that it was affecting the patient's clinical status. The MD stated that the Registered Nurses (RN) and Wound Nurse (WN) would normally be in charge of the daily care of pressure ulcers and prevention of pressure ulcers. The MD further stated that family members are informed of patient's condition by being invited to observe patient rounding on Tuesdays and Thursdays of each week. The family is encouraged to ask any questions they have regarding the patient's condition or plan of care during the hospital rounds. The MD indicated the staff would also call the family if there were a change in a patient's condition. Family members are made aware of hospital rounding verbally as part of the admission process. The MD did not remember specifically if patient#1 had wounds on the trochanter area.

During an interview with the Wound Care Nurse (WCN, Staff#1) on 10/25/16 at 12:10 p.m. in the Doctor's Charting Room, he/she stated that he/she became the WCN on 10/04/16. He/she follows all the patients in the facility, including patients that do not have any pressure ulcers or wounds on admission. The WCN stated that preventive treatment with low air loss mattresses, heel protectors, barrier creams, and a turning and repositioning schedule that is implemented every two (2) hours is given to patients without wounds. The WCN stated that at the beginning of the shift, he/she reviews the daily admission and discharge list. The nurse explained that if there is an admission during the night shift, the night shift charge nurse will do a skin assessment on the new patient, all wounds are photographed and documented in the patient's medical record.

The WCN indicated that when he/she comes in the next day, another assessment is performed to verify the measurements, location, and staging/condition of the pressure ulcers and wounds. If a new pressure ulcer develops, or if a pressure ulcer becomes worse, the WCN stated he/she would notify the MD and the family or responsible party and document the same in the patient's medical record. The WCN further stated that he/she has not had to let a family member know about a change in condition, but that he/she would document the family notification under the recommendations portion of the wound form.

The WCN stated that the RN or WCN would be responsible for the notification. The WCN indicated that if the family has questions about the status of the patient's wounds or pressure ulcers, the family is invited to attend the rounds on Tuesday and Thursday of each week. The WCN added that he/she allows the family to stay during wound care treatments, and the family is encouraged to ask any questions they might have. The further stated that all patients are pre-medicated for pain before the treatment. The WCN added that all patients that are alert are asked before, during, and after their wound treatments about premedication and their level of pain.

During a phone interview with the Registered Nurse (RN#6) on 10/25/16 at 2:10 p.m. in the Doctor's Charting Room, the RN indicated he/she remembered Patient #1. The RN stated that the patient's family was present during some of the hospital rounding, which at the time of the patient's admission, was being conducted on Tuesday and Thursday of each week. The RN stated that he/she remembered the patient had a large family, and that he/she remembered the family getting updates on the patient's pressure ulcers. The RN could not recall the exact location of patient #1's wounds. The RN stated that if there was a change in the patient's wounds, or if a new pressure ulcer had developed, he/she would have contacted the family. The RN stated that the patient was turned and repositioned every two (2) hours and did recall that the patient's heels were floated and kept in heel protectors. The RN stated that skin assessments are done daily by the nursing staff.

Based on facility policy, medical record review, and staff interviews, the facility failed to identify, assess, treat, and document the development of the patient's pressure ulcers.
Findings:-
Review of facility policy, #S05-G, "Guidelines and Protocols, Clinical," effective 05/01/2003, and last revised on 10/01/16, revealed that a systemic physical assessment was to be done and recorded on a twenty-four (24) hour flow sheet on each twelve (12) hour shift. Further review revealed that wounds were to be photographed one (1) day before discharge and that all abnormal, non-intact, non-healthy skin was to be photographed when observed. Further review revealed that the wounds were to be measured one day prior to discharge and every seven (7) days. Per policy, documentation of the wounds was to be completed weekly by the wound team, and documentation of dressing changes was to be documented on the Wound Treatment Record.
Review of the facility policy , "Wound Program Overview and Initiation Process," effective 06/10/2008, and last revised 04/01/14 revealed that at discharge, all abnormal, non-intact, non-healthy skin will be photographed within one (1) day before discharge by the Charge Nurse/Wound Nurse. Wounds would also be photographed during admission within every seven (7) days by the Charge Nurse/Wound nurse. Policy #WCII-1 also provided that the wound nurse would complete a skin/wound assessment on all patients every seven (7) days. Further, all wound care treatment would be reassessed at least every seven (7) days. A reassessment would be performed by a designated nurse and may include other members of the treatment team as appropriate. According to the policy, the team members would make rounds on all patients and perform a head-to-toe skin assessment at least every seven (7) days. Rounds would include measurement and photographic documentation of the wounds. Patient#1 was discharged on 09/09/16 to Long Term Care (LTC).
Review of the Wound Documentation Forms in Patient #1's medical record revealed that on 08/11/16, a stage II (partial loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin which contains blood capillaries, nerve endings, sweat glands, hair follicles, and other structures) pressure ulcer was noted on the patient's left lower extremity. The wound measured 5 x 2.4 centimeters. The medical record revealed that on 09/06/16, a stage III (a loss of skin in which fat tissue is visible in the pressure ulcer rolled wound edges are often present) pressure ulcer was observed on the patient's left hip area, which measured 5 x 6.3 centimeters. Additionally, an unstageable (skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is obscured by yellow fibrinous tissue and dry crusted skin) pressure ulcer was noted to the patient's right hip on 09/06/16, which measured 7.6 x 7.4 centimeters.
Review of the Braden Scale (skin breakdown assessment for predicting pressure sore risk) completed on admission and the subsequently during the months of June, July and August revealed that patient#1 was at high risk for developing pressure ulcers.
Review of the medical record for Patient#1 failed to reveal any treatments or assessments for the bilateral (on both sides) pressure ulcers the patient developed in the trochanter (hip) areas. The only documentation found in the record were photographs taken on 09/06/16.
Review of the Daily Nursing Assessment Sheet dated 06/06/16 through 09/09/16 revealed no documentation of observations, or assessment of the pressure ulcers in the patient's medical record.
Review of the Medical Doctor (MD) orders revealed that on 06/05/16, the patient was ordered pain medication as needed for pain.
Review of the MD orders dated 06/06/16 revealed a 'Dolphin' mattress (a specialty mattress used to aid in the acceleration of wound healing) was ordered for the patient for recovery care for a Braden Score of 10. Further review revealed an order for wound care as follows:-
1) protect sacrum and mid-back with (protective) foam and change every seven days and/or as needed and,
2) keep heels elevated with boots at all times while in bed.
Review of the MD orders on 06/09/16 revealed a wound care order for a skin ointment that is used for preventing and treating minor skin irritations daily and as needed for seven (7) days.
Review of the Wound Treatment Algorithm: dated 08/11/16, revealed orders for treatment to the left lower leg.
Review of the MD orders revealed that on 08/13/16 the MD wrote an order to confirm that the wound care nurse was aware of the pressure ulcer on the left heel.
During an interview with the Chief Nursing Officer (CNO, Staff#4) on 10/24/16 at 1:00 p.m. in the Doctor's Charting Room, the CNO explained that all patients are turned every two (2) hours and that the patient care technicians assist the nursing staff with the turning and repositioning of the patients. The CNO stated that all patients wear protective boots to help protect the feet and heels from skin breakdown. The CNO further stated that all patients are given preventive treatment for pressure ulcers with protective barrier creams and pads to bony prominences and areas that have extended contact with surfaces.
The CNO also stated that it was expected that the nurse or WCN would document changes to the patient's skin in the medical record and also take photographs and measurements of all affected areas, which would be included in the record.
During an interview with the Wound Care Nurse (WCN, Staff#1) on 10/25/16 at 12:10 p.m. in the Doctor's Charting Room, he/she stated that he/she became the WCN on 10/04/16. He/she follows all the patients in the facility, including patients that do not have any pressure ulcers or wounds on admission. The WCN stated that preventive treatment with low air loss mattresses, heel protectors, barrier creams, and a turning and repositioning schedule that is implemented every two (2) hours is given to patients without wounds. The WCN stated that at the beginning of the shift, he/she reviews the daily admission and discharge list. The nurse explained that if there is an admission during the night shift, the night shift charge nurse will do a skin assessment on the new patient, all wounds are photographed and documented in the patient's medical record.
The WCN indicated that when he/she comes in the next day, another assessment is performed to verify the measurements, location, and staging/condition of the pressure ulcers and wounds. If a new pressure ulcer develops, or if a pressure ulcer becomes worse, the WCN stated he/she would notify the MD and the family or responsible party and document the same in the patient's medical record. The WCN further stated that he/she has not had to let a family member know about a change in condition, but that he/she would document the family notification under the recommendations portion of the wound form.
The WCN stated that the RN or WCN would be responsible for the notification. The WCN indicated that if the family has questions about the status of the patient's wounds or pressure ulcers, the family is invited to attend the rounds on Tuesday and Thursday of each week. The WCN added that he/she allows the family to stay during wound care treatments, and the family is encouraged to ask any questions they might have. The further stated that all patients are pre-medicated for pain before the treatment. The WCN added that all patients that are alert are asked before, during, and after their wound treatments about premedication and their level of pain.
During an interview with the Registered Dietician (RD, Staff#2) on 10/25/16 at 12:35 p.m. in the Doctors' Charting Room, the RD stated that it was the facility's policy that every patient admitted to the facility be seen by a Registered Dietician within seventy-two (72) hours. The RD stated that he/she remembered Patient #1. The RD stated that the patient was admitted with pressure ulcers but was unaware of the pressure ulcers on the patient's trochanter areas. The RD stated that he/she was not made aware of those wounds until after the patient was discharged. The RD further stated that it was unusual that he/she was unaware of the patient's wounds. The RD stated he/she was surprised that the pressure ulcers had gone undocumented or that he/she had not been notified of the pressure ulcers prior to the patient's discharge as the nursing staff was historically diligent about patient's skin assessments. The RD stated that despite all of the preventive measures taken by the facility to avoid the development of pressure ulcers, some patients still develop them. The RD stated that the way the family is informed of changes in the patient ' s condition is to update them when they are visiting the patient. The RD recalled patient #1 ' s family being present during some of the meetings when the patient's status was being discussed, but he/she did not remember any conversations specifically regarding the patient's wounds.
During an interview with the Registered Nurse (RN#5) on 10/25/16 at 12:35 p.m. in the Doctors' Charting Room, the RN stated that he/she remembered he/she had taken care of the patient#1 five (5) or six (6) times during the course of the patient's hospital stay. The RN stated that the patient was turned every two (2) hours and remembered that the patient's heels were floated (supporting the heels so that the heels do not come in contact with any surfaces), and that the patient always wore heel protectors (a medical device designed to offload pressure from the heel of an individual to help prevent pressure ulcers on the bony heel area of the foot) on. The RN stated that she remembered the patient had pressure ulcers but could not remember their specific locations. The RN indicated that if there was a change in a patient's condition related to pressure ulcers or wounds, he/she would note it in the Nurse's Notes and would inform the wound care nurse about the change. the RN further stated that either the bedside RN or wound nurse should notify the family and that he/she would also document in the chart that the family was notified of the change.
During an interview with the Director of Quality Management (DQM, Staff #7) on 10/24/16 at 11:55 a.m. in the Doctor's Charting Room, the DQM stated that he/she remembered patient #1 because the patient's hospital stay was of longer duration than the average patient stay, which is normally approximately twenty (20) to twenty-five (25) days. The DQM stated that staff members are updated on a change in a patient's condition during the course of the admission when the Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion towards a common goal for the patient) meets every Wednesday. The DQM stated that during that meeting all aspects of the patient's care, changes in condition, and care issues are discussed between the disciplines involved in the patient's care. The DQM added that patient's families are invited to be present during hospital rounds (a series of professional bedside calls on hospital patients made by a doctor, nurse, or other medical staff) on Tuesdays and Thursdays so they can ask any questions regarding the patient's care and condition. The DQM stated that all disciplines are present during the hospital rounds. The DQM stated that patient #1's family should have been notified of the wounds present on the patient's trochanter area.
During an interview with Certified Patient Technician (CPT,Staff #8) on 10/26/16 at 9:50 a.m. in the Doctors' Charting Room, the CPT stated that he/she remembered Patient#1 as he/she had helped care for the patient numerous times over the course of the patient's admission. The CPT stated the patient was contracted (a condition resulting from chronic shortening of the muscles of the upper and lower limbs) and was not able to verbalize his/her needs. The CPT stated that he/she had helped with bathing the patient and remembered that the patient had some pressure ulcers. The CPT could only recall the pressures wound on the hip area and stated that the area was bandaged when he/she observed the wound. The CPT added that he/she remembered that the patient had his/her heels floated and was wearing heel protectors. The CPT stated that all patients are turned and repositioned every two (2) hours. The CPT stated that if he/she ever noted any change in the condition in a patient's skin, he/she would notify the RN immediately.
During an interview with the WCN (Staff #1) on 10/27/16 at 10:10 a.m. in the Doctors' Charting Room, the WCN indicated that prior to taking over the position of Wound Care Nurse on 10/04/16, he/she was a bedside RN in the facility. The WCN stated that he/she cared for Patient#1 during his/her admission on approximately five (5) or six (6) occasions and had done the initial assessment of the patient on admission 06/06/16. The WCN stated that the patient did not have pressure ulcers on either hip on admission and that he/she did not recall when the patient developed the ulcers.
After reviewing the medical record for Patient #1, Staff #1 confirmed that he/she was the nurse caring for the patient on 09/05/16, the day before the patient's pressure ulcers on the bilateral trochanter area were documented in the chart. Staff #1 stated that he/she had no memory of the patient having any wounds in those areas.