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Based on document review and interview the facility failed to conduct on-going patient assessments. This deficient practice had the likelihood to cause harm to all patients with pressure wounds and skin breakdown.

On 7/6/2015 in the class room at 1:00 PM the medical records (MR's) for patients (Pt/pt's) 1-16 was reviewed and the following patients were found to have skin break down during their admission.
Pt #1 was admitted with pressure wound skin break down on 3/6/2015. There were no specific measurements recorded but pictures taken on 3/9/2015 revealed a large full thickness wound to the patient's trochanter (A stage III wound which penetrated through the dermis and epidermis into the muscle but not into tendon, ligament or bone) and two smaller full thickness wounds to his buttocks with visible eschar. Picture taken on 3/16/2015 reflect an enlarged bright red wound with more black eschar (dead tissue that become black in color and leathery in texture. Eschar cannot be estimated on death) that involved the patients buttocks and scrotum.

Pt #1 was admitted from an acute care hospital with healthcare acquired sepsis and pneumonia, a protein level of 1.9 (normal is 3.5-5) and a new percutaneous endoscopic gastrostomy tube (Peg-tube). Pt #1 suffered from high protein Peg-tube formula induced diarrhea. Pt #1 was contracted in his extremities and incontinent of bowel and bladder. He was unable to make his needs known. The physician ordered the patient to be "Gotten up for large portions of the day" in an effort to improve his pneumonia and overall respiratory function.

In following the physician's order, the nursing staff failed, to assess the effects of this order on the 85 year old gentleman who was contracted and unable to communicate his needs. The nursing staff failed to recognize he was incontinent of bowel and bladder and was now sitting up, putting pressure on his buttocks and scrotal wound, and likely sitting in liquid fecal matter which contributed to accelerated skin break down. There was no documentation an attempt to control pt #1's diarrhea with a fecal management program or medication. There was no documentation options for relief or assessment of effectiveness other than every two hour position changes. Pieces of each system assessed was documented but not for the patient as a whole.

On 7/7/2015 at 2:00 PM in the class room, a meeting with the available nursing staff agreed an expectation of a new peg tube, with a high protein nutritional formula being given, would be diarrhea. There was no documentation the nursing staff was communicating with the physician to reduce the pt's diarrhea.

Pt #2. was a 77 year old gentleman admitted on 1/7/2015, to the post acute medical facility with hospital acquired pneumonia, anasarca (extreme generalized edema, a medical condition characterized by widespread swelling of the skin due to effusion of
fluid into the extra cellular space), and severe protein malnutrition among his many diagnosis. The nursing admission skin assessment documented one pressure wound a stage II to the coccyx measuring 12 cm by 10 cm by 2 cm. There was no admission photo of pt #2's coccyx wound. Upon his discharge his protein malnutrition was documented as improved, his pneumonia resolved and his anasarca resolved. However, during this hospital stay pt #2 developed four (4) wounds that were being followed by the wound care staff.
Wound #1 was on the left buttocks on 2/16/2015 it was documented as a stage II measuring 2 cm by 2 cm (centimeters)
Wound #2 was on the right buttocks. On 2/16/2015 it was documented as a stage II measuring 2 cm by 5 cm.
Wound #3 was on the left forearm. It was not staged but was described as measuring 1 cm by 4 cm and was pink.
Wound #4 was on the right thigh (medial right thigh by the picture). It was noted the junction of the Foley catheter tubing was at this level and observable in the wound picture. This wound was documented as measuring 3 cm by 2.5 cm.

Pt #3 was an 82 year old female admitted on 3/6/2015 with no wounds documented. In a photo dated 3/16/2015 pt #3 had bilateral buttocks wounds with full thickness skin breakdown visible By 3/30/2015 pt #3 had a documented stage II wound to her coccyx and her left heel. Documentation reflected no measurements and that the wounds could not be staged, however the coccyx wound was full thickness with dark pink to bright red tissue visible. The left heal wound had delineated margins. Pt #3 had a documented albumin of 2.7 on 3/15/2015 (Normal is 3.5-5).

Pt #6 was a 74 year old female patient admitted on 1/7/2015. She had a medical history of Hypertension, asthma, chronic obstructive pulmonary disease, and obesity among her many diagnoses. Documentation revealed she had no pressure areas upon admission. On 1/12/2015 wound pictures recorded a bilateral buttocks/coccyx wound that was documented as red, pink, and purple. By 1/19/2015 a picture of the same area recorded improved skin condition. On 1/23/2015 Pt #6's albumin was documented as 2.9 (Normal is 3.5-5)

Review of the policy for pt skin assessment required only weekly assessment. The nursing staff failed to utilize critical thinking in meeting the needs of pt's #1, #2, #3, and #6 to prevent the development and expansion of pressure wounds. The nursing staff routinely drew a line through the Braden scale and skin description and documented "Done on Sunday". The nursing staff assessment for the above mentioned patient's did not include daily observation and interventions more than every two hour repositioning and documentation the dressing was "Clean dry and intact". The nursing staff failed to assess methods to better off load pressure areas and prevent wound formation. The nursing staff failed to assess effectiveness of providing every two hours bowel hygiene to a patient with chronic diarrhea. The nursing staff failed to assess pt #2 for effectiveness of interventions when he developed a full thickness wound in the very close proximity to his Foley catheter tubing. The standard of care for treatment and prevention of pressure wounds is found in the following:

Journal of Long-Term Effects of Medical Implants DOI:10.1615/J Long Term Effects Medical Implants. v14.i4.20
Pressure Ulcer Prevention: There are four critical factors contributing to the development of pressure ulcers: pressure, shearing forces, friction, and moisture. Pressure is now viewed as the single most important etiologic factor in pressure ulcer formation. Prolonged immobilization, sensory deficit, circulatory disturbances, and poor nutrition have been identified as important risk factors in the development of pressure ulcer formation. Pressure ulcers can predispose the patient to a variety of complications that include bacteremia, osteomyelitis, squamous cell carcinoma, and sinus tracts. The three components of pressure ulcer prevention that must be considered in any patient include management of incontinence, nutritional support, and pressure relief.
Journal of Nursing 2001 Mar;10(6 Suppl):S42, S44-9.
The importance of patients' nutritional status in wound healing. Russell L; Good nutritional status is essential for wound healing to take place. Ignoring nutritional status may compromise the patient's ability to heal and subsequently prolong the stages of wound healing. Protein deficiency has been demonstrated to contribute to poor healing rates with reduced collagen formation and wound dehiscence. There is a correlation between low serum albumin and body mass index (BMI) and the development of pressure ulcers.
Lippincott, Williams and Wilkins 2007. The role of albumin in wound healing: Mildly depleted albumin levels are 3.0-3.4 mg/dl (milligram per deciliter), Moderately depleted albumin levels are 2.7-2.9, Severely depleted albumin levels are 2.5 and below. Albumin has a half-life of 21 days but gives a good overall view of the patient ' s ability to heal. The more depleted the albumin level, the slower the recovery process.

Based on document review and interview the facility failed to provide skilled nursing care to prevent the formation and worsening of pressure wounds for 4 of 16 debilitated patients (#1,#2, #3 and #6) from January to June of 2015.

On 7/7/2015 at 8:30 a.m. in the class room, the medical records (MR) for patients (Pt/pt)#1-#16 were reviewed. Pt's #1, #2,#3,and #6 were identified as having full thickness wounds. (A stage III wound which penetrated through the dermis and epidermis into the muscle but not into tendon, ligament or bone)

Pt #1 was admitted from an Acute Care Hospital. Physician #8's plan which was documented on the admission History and Physical revealed the following findings:
1.) "Severe debility probably related to sepsis and healthcare-associated pneumonia. The plan is to continue antibiotics and aggressive pulmonary toileting. In addition,we will seek occupational and physical therapy consult to increase his mobility and at least have him in an upright position for extended periods of the day to prevent further aspiration".
2.) "Dysphagia status post percutanious endoscopic gastrostomy tube placement (PEG-tube). The plan is to continue to feed via peg-tube. Because of his nutritional deficits, we will consult dietary services to optimize his protein and caloric intake.
3.) Sever protein malnutrition".
4.) "Decubitus and heel ulcers. We will initiate aggressive wound care with the help of our wound care team. He may need debridement of the sacral ulcer and we will continue his antibiotics as needed for optimal healing."

Pt #1's wound continued to enlarge until pt #1's buttocks, posterior scrotum, and bilateral upper posterior thighs were involved. Pt #1's wound was bright red with granulated (newly formed healthy raw tissue) and black eschar (Eschar is tissue that is dead and has become leathery in texture. It cannot be graded for depth) on his scrotum and buttocks. Upon discharge the physician (#8) documented pt #1 had Decubitus ulcers to "Heel and Buttocks". Further review of the MR revealed wound care staff had documented pt #1 had a wound to his right second toe. There was no nursing or wound care staff documentation of heel wounds. The admitting physician (#8) documented pt #1 was admitted with bilateral stage I heel wounds. Pt #1 was discharged back to the Long Term Care facility which had originally transferred pt #1 to the acute care hospital.

In following the physician's order, the nursing staff failed to consider the 85 year old gentleman who was contracted, unable to communicate his needs, and was incontinent of bowel and bladder, was now sitting up with a sacral wound, in liquid fecal matter which contributed to accelerated skin break down. There was no documentation an attempt to control pt #1's diarrhea with a fecal management program or medication. No assessment for relief was documented other than every two hour position changes.

On 7/7/2015 at 2:00 PM in the class room, a meeting with the available nursing staff was conducted and all the nurses agreed an expectation of a new peg tube with a high protein nutritional formula being given, would be diarrhea. There was no documentation the nursing staff assessed the patient's on-going diarrhea and communicated with the physician to reduce the pt's diarrhea or implement interventions to avoid and/or reduce skin irritation and skin breakdown.

Review of patient #1"s care plan documented the following: An Infection control problem was identified for aspiration pneumonia with the likely cause of infection being pt #1's new peg tube. There was no care planning for infection concerns related to open wounds with eschar to the patients bilateral buttocks, sacrum and scrotum or the fact that he was suffering from diarrhea and was incontinent. Further care plan review revealed that even though pt #1 had a large open wound to his buttocks, coccyx and scrotum that had to be cleansed frequently related to his diarrhea, his pain management was documented as "No needs to be addressed".

Pt #2 was a 77 year old gentleman admitted on 1/7/2015, to the post acute medical facility with hospital acquired pneumonia, anasarca (extreme generalized edema, a medical condition characterized by widespread swelling of the skin due to effusion of
fluid into the extra cellular space), and sever protein malnutrition among his many diagnoses. The nursing admission skin assessment documented one pressure wound a stage II to the coccyx measuring 12 cm by 10 cm by 2 cm. There was no admission photo of pt #2's coccyx wound. Upon his discharge his protein malnutrition was documented as improved, his pneumonia resolved and his anasarca resolved. However, during this hospital stay pt #2 developed four (4) wounds that were being followed by the wound care staff.
Wound #1 was on the left buttocks on 2/16/2015 it was documented as a stage II measuring 2 cm by 2 cm (centimeters)
Wound #2 was on the right buttocks. On 2/16/2015 it was documented as a stage II measuring 2 cm by 5 cm.
Wound #3 was on the left forearm. It was not staged but was described as measuring 1 cm by 4 cm and was pink.
Wound #4 was on the right thigh (medial right thigh by the picture). It was noted the junction of the Foley catheter tubing was at this level and observable in the wound picture. This wound was documented as measuring 3 cm by 2.5 cm.

Pt #2's care plan was reviewed and revealed the following:Pt #2 had two problems identified for infection risk. Pt #2 had a medi-port (subdermal port allowing for Intravenous access) and a Foley catheter. The intervention was documented as follows "reorient frequently" and "close monitoring" The expected goal was "Not experience preventable injury during hospitalization". The nursing staff failed to recognize four preventable wounds as an infection risk to pt #1.

Pt #3 was an 82 year old female admitted on 3/6/2015 with no wounds documented. In a photo dated 3/16/2015 pt #3 had bilateral buttocks wounds with skin breakdown visible By 3/30/2015 pt #3 had a documented stage II wound to her coccyx and her left heel. Documentation reflected no measurements and that the wounds could not be staged, however the coccyx wound was full thickness with dark pink to bright red tissue visible. The left heal wound had delineated margins indicating deep tissue injury that likely would deteriorate into further skin breakdown.. Pt #3 had a documented albumin of 2.7 on 3/15/2015 (Normal is 3.5-5).

Review of Pt #3's care pan revealed an Infection Control problem, identified as "High risk related to Foley Catheter". The nursing staff did not identify full thickness wounds to her sacral coccyx area as an infection control risk.

Pt #6 was a 74 year old female patient admitted on 1/7/2015. She had a medical history of hypertension, asthma, chronic obstructive pulmonary disease, and obesity among her many diagnoses. Documentation revealed she had no pressure areas upon admission. On 1/12/2015 wound pictures recorded a bilateral buttocks/coccyx wound that was documented as red, pink, and purple. By 1/19/2015 a picture of the same area recorded improved skin condition. On 1/23/2015, Pt #6's albumin was documented as 2.9 (Normal is 3.5-5).

Review of pt #6's care plan revealed although she had bilateral wounds to her buttocks, her care plan was documented as "No needs to be addressed"

None of the four patient care plans reviewed contained identification of nutritional problems. There was no need identified and no interventions offered. This indicated the nursing staff were not aware of, and did not monitor the nutritional intake of these four patient's with nutritional deficits.

Review of the policy for pt assessment (CL 39, Nursing Documentation) reflected the following identified as "H" "RN's (Registered Nurses) and LPN's (Licensed Practical Nurses) will chart subjective and objective information on the following medical record forms: 3. Daily nurses assessment" and on "K" 1. "When a functional patient problem is identified or reactivated".

The nursing staff failed to utilize critical thinking in meeting the needs of pt's #1, #2, #3, and #6 to prevent the development and expansion of pressure wounds. The nursing staff routinely drew a line through the Braden scale assessment and skin description and documented "Done on Sunday". The nursing staff assessment for the above mentioned patient's did not include daily observation and interventions more than Patient care tech's every two hour repositioning and documentation the dressing was "Clean dry and intact". The nursing staff failed to assess methods to better off load areas to prevent wound formation. The nursing staff failed to assess effectiveness of hygiene needs that were only being met every two hours. The standard of care for treatment and prevention of pressure wounds is found in the following:

Journal of Long-Term Effects of Medical Implants DOI:10.1615/J Long Term Effects Medical Implants. v14.i4.20
Pressure Ulcer Prevention: There are four critical factors contributing to the development of pressure ulcers: pressure, shearing forces, friction, and moisture. Pressure is now viewed as the single most important etiologic factor in pressure ulcer formation. Prolonged immobilization, sensory deficit, circulatory disturbances, and poor nutrition have been identified as important risk factors in the development of pressure ulcer formation. Pressure ulcers can predispose the patient to a variety of complications that include bacteremia, osteomyelitis, squamous cell carcinoma, and sinus tracts. The three components of pressure ulcer prevention that must be considered in any patient include management of incontinence, nutritional support, and pressure relief.
Journal of Nursing 2001 Mar;10(6 Suppl):S42, S44-9.
The importance of patients' nutritional status in wound healing. Russell L; Good nutritional status is essential for wound healing to take place. Ignoring nutritional status may compromise the patient's ability to heal and subsequently prolong the stages of wound healing. Protein deficiency has been demonstrated to contribute to poor healing rates with reduced collagen formation and wound dehiscence. There is a correlation between low serum albumin and body mass index (BMI) and the development of pressure ulcers.
Lippincott, Williams and Wilkins 2007. The role of albumin in wound healing: Mildly depleted albumin levels are 3.0-3.4 mg/dl (milligram per deciliter), Moderately depleted albumin levels are 2.7-2.9, Severely depleted albumin levels are 2.5 and below. Albumin has a half-life of 21 days but gives a good overall view of the patient ' s ability to heal. The more depleted the albumin level, the slower the recovery process.

Based on document review and interview the facility failed to follow its policy for discharge planning and notify the family and receiving facility of the deterioration of pt #1 and the immediate needs expected for pt's #1 and #3 of patient's #1-#16 whose medical records were reviewed from January to June of 2015.

On 7/6/2015 in the class room at 1:00 p.m. the policy for "Plan of Care Process" was reviewed and revealed the following:
1. "Care Plan is initiated by an RN (Registered Nurse) on admission".
2. "The Care Plan should include current admitting diagnosis and any diagnoses that are being actively addressed during the hospital stay".
3. "Care Plan is reviewed and updated every 24 ours by a RN (Charge nurse)".
6. "The care plan will be used by nursing staff and current interventions will be documented".
8. "A new team conference form will be completed weekly by the appropriate discipline and discussed during the team conference along with the plan of care.
Nursing leadership is responsible for 100% care plan audits to ensure compliance of daily review and intervention".

Review of the "Assessment -Reassessment Nutritional Services" revealed the following:
Policy: "A nutritional assessment is completed on all patients admitted to the hospital. Assessment, planning, interventions and evaluation is used to help determine the patient's needs and plan of care".
Procedure:
1. "The registered dietitian initiates an initial nutritional assessment and the nutritional care process (NCP). as defined by the Academy of Nutrition and Dietetics, within 72 hours of admission (or per state regulations) for all patients.
In collaboration with the patient, family member or responsible party, and interdisciplinary team, the registered dietitian utilizes the nutritional care process".

Review of the Policy for "Discharge Planning", revealed the following: "Case Manager, Social Workers and other members of the healthcare team, will collaborate with patients, families' physicians, healthcare team members, and community resources to ensure that patients have a plan of continued care after they are discharged from the hospital".

"Case Managers, Social Workers and other members of the healthcare team will provide individual discharge planning to each patient through assessment of discharge needs at admission, development of a discharge plan, implementation of the plan, evaluation of the appropriateness of the plan with on-going monitoring and coordination of final preparations for discharge.
1. The level at which the patient and family or other caregivers understands the patient's medical condition and the reason for hospitalization.
2. The patients stated expectations
3. Tasks the patient can/cannot accomplish as a result of their current health problems
6. Language and language barriers
7. Physical and/or cognitive limitations
12. Levels of post -hospital care needs (Home, intermediate,long term etc)"

On 7/7/2015 in the class room, the medical records (MR) for patients #1-#16 were reviewed and revealed the following. Patient's #1 and #3 were discharged with pressure wounds that required treatments which likely would include a specialty bed or mattress. Review of the discharge planing documentation for both patients #1 and #3 revealed the following documentation:
Pt #1: Case Management's single note dated 3/12/2015 at 1400 hours (2:00 PM) "Attempted to reach family to discuss current condition report. New wound care orders per wound care... ". There was no documentation of a follow up attempt to reach the family. Prior to, or on the date of, discharge there was no documentation of contact with the family or the facility the patient would be discharged to. There was no documentation the facility was given advance knowledge of the condition of the patient or equipment that would include wound care dressing and possibly a low air loss mattress.

Pt #3: A review of case management notes identified the following entry:
3/18/2015; "Met with daughter today and discussed recent peg tube placement, and that has made unusual progress with PT (physical therapy) OT (occupational therapy) and ST (speech therapy) and doubtful will be candidate for acute rehab and most likely will need SNF (Skilled Nursing Facility). They requested a facility".
3/23/2015 "Per family request contacted the facility of choice and faxed clinical information". The entry did not clarify what part of the clinical information was faxed. Since the History and physical did not document any of pt #2's wounds it is unknown if the receiving facility was aware of the needed wound care supplies or specialty bed likely needed prior to receiving pt #2.

Interview with the receiving SNF facility staff indicated they had discharge pt #1 to the acute care hospital with no skin problems. They were surprised at the wound pt #1 had. They voiced no awareness of pt #3's wound either. A review of the clinical information available for both patients did not include measurements or grading of either pt's wound. Only pt #1 discharge summary documented "Decubitus and heal wound". No further data or explanation was documented. Long Term Care Facilities seldom have budgets to purchase specialty beds and or mattresses and these musts be ordered from a Durable Medical Supply company. Immediate use is not an option for wound care patients upon admission unless arraignments have been made via hospital case management.

The failure of case management to document factual information related to Pt #1 and #3's medical condition and to communicate that information upon discharge to the receiving nursing facility placed both patients at risk for immediate care needs being delayed.