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Based on medical record reviews, interviews and review of policies and procedures, the hospital failed to provide head to toe skin assessments, identify wounds and document a description of the wounds within four hours of admission, for Patient Identifiers (PI) # 1 and PI # 2, two of ten sampled patients. This deficient practice has the potential to affect all patients.

Findings Include:


Policies and Procedures:

A. Policy Number: HD - NUR 401.04
Effective Date: 6/1/13
Revision Date: 4/17/13

I. Admission Assessment

1. "...It is the RN's responsibility to perform a physical assessment of the patient within four hours of admission....this assessment shall include: ...Skin/wound assessment."


B. Policy Number: HD - NUR 406.65
Effective Date: 1/24/11
Revision Date: 1/24/11

Guidelines: Pressure Ulcer Staging

"The initial assessment and staging of wounds constitutes a practice beyond the basic educational preparation of the Registered Nurse as identified by the Alabama Board of Nursing. Therefore the initial assessment and staging of wounds will be performed by a Registered Nurse who has been trained and who completes the required updates..." The policy does not indicate a time frame for this assessment.


Medical Record Review:

1). PI #1 was admitted on 10/2/13 with diagnoses to include:

1. Respiratory failure requiring mechanical ventilation and tracheostomy ( A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe).
2. Cervical spine injury.
3. ...forearm injury with immobilizer cast.
4. ...ankle fracture with immobilizer cast.
5. Motor vehicle accident...
12. T 10 Compression fracture.
13. Moderate protein calorie malnutrition..


A review of PI # 1's Nurse's 24 Hour Assessment and Progress Record (Wound Care section of the form) dated 10/2/13 at 19:10 reveals, "OA coccyx noted." "OA" is not defined. There is no documentation about PI # 1's wound(s) in the daily wound assessment section of the form. There is no description of the color of the wound bed, the condition of the surrounding skin, drainage, odor, clinical signs of infection and action taken.

The narrative nursing note dated 10/3/13 at 00:05 reveals no further information regarding the "OA" on PI #1's coccyx.

A review of the documentation by the Wound Care and Ostomy Nurse (WCON) indicates three wounds were identified during the WCON's evaluation of PI # 1's skin on 10/4/13 at 1:15 PM:

1. Wound Location: Head - Posterior:
Wound Type: Pressure.
Wound Size: 0.4 (Length) x 4.0 Width x Depth 0.0
Assessment Date: 10/4/13
Admission Date: 10/2/13
Wound Discovered: 10/2/13
Present on Admission? Yes
MD Notified? Yes. Notified Date: 10/4/13

Special Instructions: Mepilex foam x 2 weekly.

Current Treatment: "Unable to visualize area. Patient complained of 'unremovable' neck brace pressing on back of her head, it feels closed to palpation. Mepilex (absorbent soft silicone foam dressing) placed between the brace and ...skin..."


2. Wound Location: Right Heel.
Wound Type: Pressure.
Wound Size: 4.0 Length (L) x 6.5 Width (W).
Assessment Date: 10/4/13
Admission Date: 10/2/13
Wound Discovered: 10/2/13
Present on Admission? Yes
MD Notified? Yes. Notified Date: 10/4/13


3. Wound Location: Sacrum.
Wound Type: Pressure.
Wound Size: 10.0 (L) x 9.0 (D)
Assessment Date: 10/4/13
Admission Date: 10/2/13
Wound Discovered: 10/2/13
Present on Admission? Yes
MD Notified? Yes. Notified Date: 10/4/13


According to the Wound Care and Ostomy Nurse's documentation on 10/4/13 at 13:15, two days after PI # 1 was admitted, all three of PI # 1's wounds were present on admission. The WCON identified two wounds (head and right heel) on 10/4/13 at 1:15 PM that were not identified and documented by the staff Registered Nurse (RN) within four hours of PI # 1's admission on 10/2/13 as required per hospital policy. There is no documentation by the staff RN to support the WOCN's documentation that PI # 1's wounds to the posterior head or heel were identified on admission.


A review of PI # 1's Admission Orders, dated 10/2/13 at 17:16, reveal..., "Wound Care Nurse to evaluate and recommend treatment plan..."


A Physician's order dated 10/4/13 at 14:15 and written two days after PI #1's admission reveals:
- Mepilex foam to R (Right) heel/under valved cast 2 x (times) weekly and prn (as needed);
- Mepilex foam on back of head under neck collar 2 x per week and prn;
- Mepilex sacral 2 x weekly and prn.

As a result of this deficient practice two out of three wounds on
PI # 1's skin were not identified, described or documented by the staff Registered Nurse (RN) within four hours of admission as specified by hospital policy. The single wound that was identified on admission was not described. Documentation by the WOCN reveals all of PI # 1's wounds were identified on admission.



2). PI # 2 was admitted on 12/6/13 with diagnoses to include:
1. Hypotensive Shock from Septicemia.
2. Bacteremia.
3. Intravascular Volume Depletion.


A review of the Wound Care section of the Nurses's 24 Hour Assessment and Progress Record, dated 10/2/13 at 20:30, reveals no documentation that PI # 2 had any wounds on admission. There is no documentation in the Daily Wound Assessment section of the 24 Hour Assessment Form regarding any wounds on PI # 2.

A review of the Nurse's Narrative Notes dated 12/6/13 at 20:30 reveal, "Pt. (patient) extremely edematous with multiple skin tears and fragile skin."


A review of the documentation by the Wound Care and Ostomy Nurse (WCON) regarding PI # 2 on 12/9/13 at 5:52 indicates:

- Five wounds were present on admission on 12/6/13.

- The location of these wounds include:

1. Wound Location: Back (Scapula) - Right
Additional Location: Across back "L/R" (Left/Right)
Wound Type: Open Lesion
Wound Size: 25.0 (L) Length x 25.0 (W) Width
Wound Discovered: 12/6/13
Present on Admission? Yes
Admission Date: 12/6/13
Date MD Notified: 12/9/13


2. Wound Location: Abdomen -Midsection
Wound Type: Open Lesion
Wound Size: 25.0 (L) x 25.0 (W) x 0.1 (D) Depth
Wound Discovered: 12/6/13
Present on Admission? Yes
Admission Date: 12/6/13
Date MD Notified: 12/9/13


3. Wound Location: Hip (Trochanter) Right
Wound Type: Pressure
Wound Size: 3.0 (L) x 3.0 (W)
Wound Discovered: 12/6/13
Present on Admission? Yes
Admission Date: 12/6/13
Date MD Notified: 12/9/13


4. Wound Location: Ishium - Right
Wound Type: Pressure
Wound Size: 2.0 (L) x 4.0 (W) x 0.1 (D)
Wound Discovered: 12/6/13
Present on Admission? Yes
Admission Date: 12/6/13
Date MD Notified: 12/9/13


5. Wound Location: Sacrum
Wound Type: Pressure
Wound Size: 8.0 (L) x 10.0 (W) x 0.5 (D)
Undermining (Area of tissue destruction extending under intact skin along the periphery of a wound):
12 o'clock Depth: 2.0 cm.
3 o'clock Depth: 2.0 cm.
6 o'clock Depth: 2.0 cm.
9 o'clock Depth: 2.0 cm.
Wound Discovered: 12/6/13
Present on Admission? Yes
Admission Date: 12/6/13
Date MD Notified: 12/9/13



None of PI # 2's five wounds were identified on admission or within four hours of admission on 12/6/13 by staff Registered Nurses, but were identified three days later (12/9/13) by the Wound Ostomy Care Nurse (WOCN). Physician orders for wound care were not written until three days after PI # 2 was admitted and evaluated by the WOCN. Documentation by the WOCN reveals all of PI # 2's wounds were identified on admission.



During an interview on 12/9/13 at 3:15 PM the Nurse Manager, Employee Identifier (EI) # 1 verified there is no documentation regarding Patient Identifier # 1's wound by the admitting RN on 10/2/13 at 18:05. The Nurse Manager reviewed the nursing assessment on 10/3/13 at 19:10 that documents "OA" coccyx by the staff RN. The manager defines "OA" as open area. Because the two RN's responsible for the documentation on 10/2/13 and 10/3/13 are no longer employed by the hospital they were not available for interview.


During an interview on 12/9/13 at 11:10 AM, the Director of Clinical Services (EI # 2) verified the first documentation by the staff RN about the wounds on PI # 2's sacrum and scapula was on 12/7/13, seventeen and one half hours after the patient was admitted.


During an interview on 12/9/13 at 11:10 AM, the Wound and Ostomy Care Nurse (WOCN), EI # 4, verified the measurements for PI # 1's wound to the posterior head were 0.4 (L) x 4.0 (W) during the WCON's skin assessment on 10/4/13. The surveyor asked how these measurements were obtained because the WCON also documented the wound was not visible. The WCON verified the wound could not be seen because it was located under PI # 1's neck brace. However, wound measurements must be entered in order for the computer program to advance to the next page.


During an interview on 12/10/13 at 14:15 the Director of Clinical Services, EI # 2, said the RN (Registered Nurse) responsible for admitting a patient should do a head to toe skin assessment and document the location and description of any wounds. The Wound Care Nurse (WCON) is to evaluate patients within 72 hours of admission to stage and measure pressure ulcers etc...and recommend wound care treatment. Regarding PI # 1, the DCS (EI # 2) said she "assumed" Mepilex dressing was used on the patient's coccyx from the time of admission (10/2/13 at 18:05) until 10/4/13 at 16:15, after PI # 1 was evaluated by the WCON. There are no wound care orders documented prior to 10/4/13.

The hospital policies regarding Admission Assessment and Pressure Ulcer Staging are contradictory. According to the Admission Assessment Policy it is the RN's responsibility to perform a physical assessment of the patient to include a skin assessment within four hours of admission. However, the Pressure Ulcer Staging Policy indicates, "the initial assessment and staging of wounds constitutes a practice beyond the basic educational preparation of the Registered Nurse...Therefore the initial assessment and staging of wounds will be performed by a Registered Nurse who has been trained..."


ALLEGATION NUMBER # 2 : 482.41 Physical Environment

Based on observations and interviews, the hospital failed to maintain a clean and safe environment in 6 of 27 patient rooms.

Findings Include:

During a tour of the hospital on 12/9/13 beginning at 9:20 AM with Employee Identifier (EI) # 3, Day Shift Charge Nurse, physical environment concerns were identified in the following patient rooms:

- Room 567: Gray colored dust was seen on the vents of the air conditioning/heat wall unit.

- Room 571: Brown colored debris/dirt was seen in the bottom of the wall unit.

- Room 568: Dirt was observed in the bottom of the wall unit.

- Room 566: Brown colored debris was observed in the bottom of the wall unit.

- Room 564: A large area of chipped and missing paint was observed on the wall (area above the head of the bed). Light Gray colored dust was seen on the vents of the wall unit.

- Room 583: A black substance was seen on the vents of the wall unit. The substance adhered to the surveyor's fingers after it was touched.

During an interview while touring the hospital on 12/9/13 at 9:50 AM, the Day Shift Charge Nurse (EI # 4) verified the debris seen by the surveyor in the bottom of the wall unit in room 566 and the black substance found by the surveyor on the vents of the wall unit in room 583.