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Based on interview and clinical record review, the facility failed to ensure the registered nurse supervised the nursing care for Patient #2, #6, and #10 to ensure the facility's own policy regarding skin care was followed. This included not having a skin risk assessment and photographs taken on admission for compromised skin areas of Patient #2 and #10, and not having a skin risk assessment, photographs of compromised areas on discharge, and documented wound description for Patient #6. The sample size was ten patients. The Hospital census was thirteen patients.

Finding:

The clinical record review for Patient #10 was completed on 02/18/10. The clinical record review revealed the Patient #10 was admitted to the facility on 08/31/09 and discharged on 09/24/09. The clinical record review revealed a discharge summary dated 09/24/09 that stated she was admitted with diagnoses that included respiratory failure, subarachnoid hemorrhage secondary to an aneurysm, and aphasia.

The clinical record review revealed the patient was admitted to the facility on 08/31/09. The clinical record review revealed the patient was assessed as having excoriated buttocks. The clinical record review revealed the Patient #10 was assessed as being unresponsive to verbal stimuli. She was assessed as being incontinent of stool, and having an indwelling urinary catheter for urinary elimination. The patient was assessed as having a feeding tube for nutritional support. The patient was noted to have a tracheostomy for respiratory support. The patient was assessed to have moderate to severe neurological disability. The patient was assessed for motor movement and found to withdraw from painful stimuli only. The clinical record review did not reveal where a pressure sore risk assessment (as known as a Braden scale) was completed on admission. The clinical record review did not reveal where a photograph was taken of the excoriation on the buttocks.

Review of the nurse's notes revealed notes on 08/31/09, 09/01/09, and 09/04/09 that stated Patient # 10's coccyx was excoriated.

The clinical record review of the nursing notes completed on 02/18/10 revealed Patient # 10's skin was assessed at least twice a day: in the morning and in the evening. Review of the nursing notes dated 09/17/09, 09/18/09, and 09/23/09 revealed Patient # 10 had excoriation to the buttocks on those days.

The clinical record review revealed a physician's order dated 09/17/09 at 11:00 A.M. that stated to apply protective cream to coccyx twice daily and as needed.

The clinical record review did not reveal where this was done.

For skin care, the nursing notes between 08/31/09 and 09/24/09 were reviewed. The review revealed the patient was repositioned every two hours save for two days, 09/08/09 and 09/10/09.

The clinical record review for Patient #2 was completed on 02/18/10. The clinical record review revealed the patient was admitted to the facility on 02/11/10 with the principal reasons for admission being pressure ulcers to the right ischium and both heels. A review of a patient's history and physical (dated 01/25/10) stated the patient was a quadriplegic secondary to a gunshot wound.

The clinical record review did not reveal where a Braden scale assessment was performed or where photographs of the patient's wounds were taken on admission.

The clinical record review revealed photographs were taken on 02/15/10. The photographs revealed a left heel ulcer 4.5 centimeters long by 4.5 centimeters wide, a left foot ulcer 2 millimeters long by 3 millimeters wide, a right ankle wound 4 centimeters long by 2.5 centimeters wide, an ischial wound 6 centimeters long by 10 centimeters long and 3.5 centimeters deep, and on the bottom of the left foot a wound one centimeters long by 5 millimeters wide.

A review of the facility's wound assessment policy and procedure as revised on 12/08 was completed on 02/18/10. The review revealed:

"All patients admitted to (the hospital) will have a skin assessment on admission and daily thereafter.

Patients admitted for wound care will have a comprehensive assessment of the wound on admission and weekly thereafter. The assessment of a wound will include at a minimum location, size, tunneling, undermining, drainage, odor, color, and surrounding tissue. Pressure ulcers will be staged by the Wound Care Team. Photographs of the wound will be taken on admission, weekly and on discharge as part of the wound care team assessment."

On 02/17/10 at 3:45 P.M. the surveyor interviewed Wound Care Nurse #1. The surveyor asked Wound Care Nurse #1 what all the skin assessment mentioned in the policy entailed. She said it included a Braden scale assessment. She confirmed that neither Patient #2 nor #10 had received a Braden scale assessment on their admission. She confirmed that neither Patient #2 nor #10 had photographs taken on their admission.



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The medical record for Patient #6 was reviewed on 2/18/10. The patient was admitted on 12/17/09 and discharged 12/28/09. The patient was admitted for leukocytosis, acute renal failure, coccyx wound, and severe diarrhea. The patient had history of HIV positive. The admission wound care orders dated 12/17/09, timed 4:40 P.M. read wound care coccyx, cleanse with normal saline, pack with Aquacel and abdominal pad, left foot cleanse with normal saline, apply 4x4 dressing and Kling. The right buttock order ws written as cleanse with normal saline, apply Aquacel and 2x2 dressing. The order lacked a frequency for dressing changes. The patient had a fecal management system and Foley catheter.

The nursing admission database dated 12/17/09 revealed the patient had a coccyx wound. The education assessment on the database revealed the patient would need bowel and bladder care and skin and wound care. The narrative revealed the shift nurse cleansed the patient and applied a dry sterile dressing to left ischial wound after admission at 9:50 P.M. The nurse note revealed on 12/18/09 the nurse changed dressings to the coccyx and ischial wound.

The record contained one photograph of a wound dated 12/17/09. The narrative stated the type of wound was a pressure ulcer stage III. The narrative with the photograph lacked location of the wound, the graphic location was incomplete. The measurement of depth, presence of exudate, description of wound bed, surrounding skin color, and description of wound edges was incomplete. The photograph was not signed by a nurse.

The record lacked photographs and measurements of other wounds mentioned in the nurse narrative on assessment on 12/17/09. The nurse narrative on the 12/17/09 referred to a left ischial wound. The admission wound care orders did not have orders for a left ischial wound dressing that was performed by the nurse on 12/17/09.

The record lacked a Braden scale as required by policy.

The record lacked weekly photographs and discharge photographs of the patient's wounds. The record lacked specific wound care performed on each wound by the staff nurses. Interview with the Director of Clinical services on 12/18/09 revealed the facility was without a wound care nurse during this patient's admission. The CEO confirmed the wound care nurse had terminated employment on 12/8/09.

Review of the physician progress note dated 12/19/10 revealed on exam of the patient's back, the patient had a stage 4 decubitus ulcer, which appears clean with no signs of infection. Physician #1 wrote there is also another stage 2 decubitus ulcer on the left ischium.

The record lacked a discharge summary from the attending physician prior to exit on 12/19/09.

The CEO presented on 12/19/09 a patient transfer form for patient #6 signed by the physician on 12/26/09 with the planned date of transfer as 12/28/09. The form listed wound care to be done as coccyx: cleanse with normal saline, pack with Aquacel and abdominal pad daily. Left foot: cleanse with normal saline, apply 4x4 and Kling daily. Right buttock: cleanse with with normal saline, apply Aquacel and 2x2 daily. The transfer order lacked evidence of a left ischial wound.

The wound care policy review as revised on 12/08 was completed on 02/18/10 stated photographs were to be taken on admission, weekly and on discharge as part of the wound care team assessment.

Interview with Quality Manager on 02/18/10 at 3:00 p.m confirmed the finding of the record stated the type of wound was a pressure ulcer stage III. She confirmed the narrative with the photograph lacked location of the wound, the graphic location was incomplete. She confirmed the measurement of depth, presence of exudate, description of wound bed, surrounding skin color, and description of wound edges was incomplete. She described the wound to the surveyor as approximately 3 centimeter in length according to the ruler that was captured in the photograph. The Quality Manager stated, "I think this is a head wound".

Telephone interview with Physician #1 on 2/19/10 at 10:00 A.M. revealed his main concern was for the infectious process and the chronic diarrhea for Patient # 6. He stated the dictation may have been interpreted incorrectly because of his accent. The surveyor asked the physician if he could recall the location of the stage IV wound because it was not documented. He stated the wound was somewhere in the gluteal area.

Interview with the CEO on 2/19/10 regarding the lack of a discharge summary in the record revealed the physician had left the area and the hospital was unable to reach the physician.