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Based on interview, observations, and medical record review, it was determined that the hospital's clinical staff did not ensure care was evaluated and supervised for 3 of 8 patients. Specifically, the professional staff did not actively monitor fragile, elderly patients to assure they were free from skin breakdown. Patient identifiers: 1, 5, and 6

Findings include:

An interview was conducted with the clinical nurse manager for the geropsychiatric unit of the hospital on 9/19/2011. The nurse manager explained that all patients admitted to the unit had a thorough skin assessment upon admission and at least every day. The nurse manager stated that photographic evidence was used to assure all patients admitted had documentation of skin assessments. The nurse manager stated that the facility followed a protocol that any patient who had an apparent breakdown was referred to the wound clinic for an evaluation and if necessary treatment. The nurse manager presented a "wound care binder" in which details regarding patient assessment were to be carried out by the nursing staff and stated that everyone on the unit had been trained on the protocol.

The manager was asked to present a protocol for cleansing the skin when the patient was incontinent. The manager showed the state surveyor the tools for staff to use which consisted of aloe wipes, followed by barrier cream or a spray to the peri area. The clinical manager stated that everyone knew the protocol. The surveyor asked to review the protocols. The manager presented two. One for urinary incontinence and fecal incontinence. Both protocols were reviewed. The "incontinence management, urinary" protocol listed on page 6 at the bottom of the page : to frequently assess the patient's mental and functional status, regularly remind to void, respond to calls promptly and help to the bathroom quickly, clean the perineal area frequently, apply a moisture barrier cream, and document the procedure. The protocol "Incontinence management, fecal" on page 2 was to "maintain effective hygienic care to increase the patient's comfort and prevent skin breakdown and infection. Clean the perineal area frequently with a skin cleaner, and apply a skin protectant cream after every incontinence episode".

On 9/19/2011, the state surveyor conducted a skin check with the unit's charge nurse on patient 1. Patient 1 was ambulatory and consented to a skin check. The nurse removed the patients shoes for a heel check and pulled down the patients pants to check the buttocks. Patient 1 was observed to have two small breaks in the skin around the coccyx area (approximately 1/4" in length). The RN stated she was surprised to see this as the patient was ambulatory. The nurse explained that the patient had an old healed area on the right buttock. The patient was noted to have a nickle sized indentation and darkly discolored area on the right buttock. The area was completely healed over. Medical record review was conducted and on 8/11/2011 staff documented "right buttock". There was no description of what that meant. On 8/25/2011, staff documented "right buttock with wound dssg (dressing) changed". There was no other information under the skin assessments to describe patient 1's "wound". Documentation from 9/9/2011 to 9/18/2011 for skin was described as "wnl".
Patient 1 had a nursing care plan that was updated according to her psychiatric diagnosis but nothing regarding skin, dressing changes, or interventions.


On 9/19/2011, the state surveyor observed a brief change for patient 5. Patient 5's wet brief was removed, barrier cream was placed on the buttocks and a new brief was placed. Patient 5's buttocks were red and was noted to have a small open area on the right buttock. The nurse stated the area appeared to be vesicles and that she had not been taking care of this patient so she was not aware of the condition of the skin. The nursing assistant was present during the brief change and made no comments regarding the skin.

A review of patient 5's electronic flow chart evidenced documentation at least daily and on some days as much as 3 times a day regarding skin assessment. Each note indicated skin was "wnl" (within normal limits) with the exception of 8/17/2011 a note "coccyx is red". There was no other mention of a problem with skin or that the care plan was updated to provide additional interventions for skin breakdown.


Patient 6 was admitted on 3/11/2011 after having increasing agitation at his residence. The history and physical contained documentation that patient 6 had become increasingly agitated, combative, hitting staff intentionally, has had to have restraints and has been hitting the walls. The physician documented that patient 6 had multiple skin tears and bruises from all his agitation and with his episodes of combativeness. The physician also documented that patient 6 had a long history of taking steroids for asthma which had left his skin quite fragile. Physician orders dated 3/12/2011 included "daily wound care to both arms". The physician's discharge note written 3/25/2011 contained information that patient 6's skin tears and bruises were healing.

Behavioral Assessment notes (nursing documentation) were reviewed for patient 6 from 3/12/2011 to 3/25/2011. Documentation for wound care was found on 3/12/2011 for the evening/night shift and on either 3/18/2011 or 3/19/2011. The note was not dated or signed but did state the dressing to "arm changed".

Review of nursing documentation of the electronic flow sheets for skin contained the following information:

1. 3/13/2011-multiple skin tears on upper extremities, dressing intact, dry, no drainage
2. 3/14/2011-skin assessments and intervention "per protocol" documented on the night shift, day shift documentation for skin "wnl" (within normal limits) and evening shift documented assessment "per protocol"
3. 3/15/2011-3/17/2011- "wnl"
4. 3/18/2011-evening shift documented healing skin tears on arm and the night shift documented no breakdown
5. 3/19/2011-documented at 10:10 AM skin "wnl" multiple tears and bruises upper arms
6. 3/20/2011-no documentation
7. 3/21/2011-"wnl"
8. 3/22/2011-documented skin tears covered
9. 3/23/2011-3/24/2011-no documentation and
10. 3/25/2011-documented very delicate skin, many skin tears to bilateral arms.

During the survey, 8 medical records were reviewed (3 closed and 5 active). Each of the eight patients were noted to have a care plan and each care plan was geared toward psychiatric goals and interventions. Each of the patients care plans contained a "risk for falls" with interventions such as bed or chair alarms. None of the 8 care plans contained measures for monitoring skin for tears, wounds, or incontinence care.

Medical record review evidenced that skin checks were being documented routinely for all eight patients, however, there was no documentation that staff were using protocols for incontinence care, or turning unresponsive patients on a routine schedule or providing preventative measures on unresponsive patients such as padding ankles, floating feet, assessing all bony prominences to assure no breakdown. All patients did receive a physical therapy consult and for bed bound or chairfast patients did have documentation of range of motion treatments.


Documentation from the psychiatric technicians (nursing aides) evidenced that patient checks were done every 15 minutes on patient 6. The documentation consisted of what patient 6 behaviors were. Documentation revealed increasing instances in which patient 6 was in bed asleep or in a wheelchair asleep. Nursing documentation also consisted of increasing sleeping or episodes in which patient 6 could not be aroused. There was no information in the nursing care plan that provided interventions for turning on a routine schedule, or providing routine brief checks for incontinence and cleaning of skin following incontinence or any preventative measures such as floating feet on pillows to prevent skin breakdown on a patient who had very fragile skin.

The clinical nurse manager was asked on 3/19/2011 what "wnl" meant under the skin assessment and stated that it meant within normal limits meaning there were no problems identified.

Based on interview with the clinical manager, medical record review and observations it was determined that the facility's nursing care plan did not encompass all of the patients' needs. Specifically, the nursing care plans did not provide interventions or goals for 4 of 8 patients who had skin breakdown or potential for skin breakdown. Patient identifiers: 1,3,5, and 6

Findings include:

On 9/19/2011, the neruopsychiatry unit was observed. Several patients were noted to be sitting in front of the nursing station in wheel chairs, geri chairs, regular chairs and some walking in the hallway. The state surveyor picked 5 active patients to conduct chart review and requested that the registered nurse (RN) accompany the surveyor in assessing those 5 patient's skin. The surveyor requested the skin checks be limited to feet and buttocks.

Patient 1 was noted to be up ad lib and was one of the patients observed walking in the hallway. Patient 1's skin check revealed both feet (heels) to be clear but 2 small stage II (break in skin) skin tears were noted around the coccyx area. The RN was aware of an old healed area on the right buttock. The RN expressed surprise about the stage II as patient 1 was up walking around. (Stage II is a partial thickness skin loss that presents as an abrasion, blister or shallow crater)

Patient 1's medical record was reviewed specifically for skin assessment. Patient 1 was a elderly person admitted to the hospital on 8/9/2011. Admission skin assessment was completed on 8/9/11 with no problems identified. The flow sheet on 8/11/2011 noted under skin "right buttock" but no description was noted. On 8/24/2011 the skin assessment documentation was "right buttock w/wound-dssg (dressing) changed". On 8/25/2011 the skin was assessed as "wnl" (within normal limits). The rest of the skin assessments up to and including 9/18/2011 were documented as "wnl".
Patient 1's care plan was reviewed and evidenced care planning for the psychiatric condition. There was no plan regarding assessments and interventions in caring for patient 1's skin.

Patient 3 was a 85 year old admitted 8/28/2011 with depression. Patient 3 was admitted with known herpes virus on her buttocks. The care plan evidenced psychiatric interventions but did not address interventions on how to care for the herpes and patient 3's incontinence issues.

Patient 5 was an 84 year old admitted on 8/1/2011. Patient 5 was noted to be sitting in a geri chair when the surveyor walked on the unit. The surveyor requested that the RN assist in checking patient 5's feet and buttocks. The patient was not responding to any verbal stimulation when the RN approached him. The RN and the aide attempted several times to arouse patient 5 to lay him on the bed for the skin check. Patient 5 was partially lifted by the RN and aide and placed on the bed. The patient's socks were removed and both feet were checked and no pressure areas were noted. The patient's urine soaked brief was then removed and the nurse slid the patient over to the edge of the bed and turned him over for the state surveyor to observe the buttocks. Patient 5's buttocks area was a bright red and appeared to have a small stage II area on the right buttock. The RN pointed to the area and stated that it looked like "herpes" or vesicles. The nurse asked the aide to give her barrier cream and proceeded to put the cream over all the redden areas and replaced the brief.

Patient 5's care plan and skin assessment flow sheet were reviewed. The flow sheet documentation revealed daily or more assessments of skin with no issues noted. The care plan was specific to psychiatric interventions. There was no information in the care plan that interventions were in place to assure there was no skin breakdown for a patient who was unresponsive/non arousable.

Patient 6's closed medical record was reviewed. Patient 6 was an 80 year old admitted for change in behaviors. Patient 6's medical record evidenced that he had multiple skin tears and bruises. During the coarse of his admission from 3/11/2011 to 3/25/2011 there were multiple assessments documented regarding skin. The physician documented in the admission history and physical that patient 6 had very fragile skin due to steroids and that he had multiple bruises and tears on his arms. Nursing documentation added a bruise to the right toe. Patient 6 was assessed as a high risk for falls and a high risk for danger to himself and others due to his agitation. Staff in the emergency room (ER) (where patient entered the system) documented that patient 6 was so combative that he had sustained skin tears in the ER. The physician and advanced practice nurse documented in multiple notes about the skin tears and bruises.
Physician orders on 3/14/2011 were: daily wound care to both arms. There was no documentation in the medical record that evidenced nursing was doing daily wound care. Flow records of skin assessments were reviewed and were inconsistent on a daily basis regarding skin. For example, some days patient 6 was listed under friction/shear as a problem, other days a potential problem. Some days the staff documented skin "wnl" and other days there was documentation of the skin tears. There was no documentation of dressing changes and the care plan revealed that patient 6 was a risk for falls but there was never any care planning for potential to develop pressure sores. Patient 6 spent a majority of his time in bed asleep according to the psychiatric technicians observations, yet there were no documented interventions planned to assure no skin breakdown.