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Based on review of the patient clinical record and interview with staff, patient #1 developed bilateral heel decubitus during his stay at the rehab hospital, therefore the hospital failed to provide care in a safe setting.

Findings were:

Patient #1 was admitted on 12/8/10, the skin on his feet was intact. On 1/12/11 the nursing staff documented wounds to bilateral heels. On 1/13 the wound care nurse evaluated the areas. The physician ordered " Mepilex dressings to be changed daily. " He was discharged to home with home health care on 1/22/11 with open, draining wounds to his bilateral heels. Pictures and interview with the nursing director confirm these findings.

Based on review of the record for patient #1 and interview with staff, the hospital failed to ensure supervision and evaluation of the nursing care provided to this patient.

Findings were

Patient #1 was admitted to this rehab facility on 12/8/10, with the skin on his feet intact. On 1/12/11 the nursing staff documented wounds to bilateral heels. On 1/13 the wound care nurse evaluated the areas. The physician ordered per recommendation of the wound nurse " Mepilex dressings to be changed daily. " On the 14th one heel was described with black areas and one with a scab. On the 15th the heel description was - the dressings were clean dry and intact. On the 16th the description was " 2 bilateral heels. " On the 17th through the 20th the area for wounds was documented as " intact " . On the 17 there was no description of the wounds. On the 18th the area was described as " dressing on, skin intact. " On the 19th and 20th the areas were documented as intact, and on the 20th " wound care nurse changed dressings. " On both the 21st and the 22nd the area was marked " wound care nurse changes dressings " . He was discharged to home with open draining wounds to his bilateral heel on 1/22/11. Pictures and interview with the nursing director confirm these findings.