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Based on medical record review, interviews and review of policies and procedures, the hospital failed to develop and implement a nursing care plan to address Skin and Wound Care for Patient Identifier (PI) # 1, a diabetic patient admitted with existing pressure ulcers and a left below the knee amputation, As a result, the care plan failed to reflect changes in existing pressure ulcers or the development of new pressure ulcers acquired after PI # 1 was admitted on 11/18/2011.

A review of the Nurses's 24 Hour Assessment and Progress Records (12/3/2011 through 12/7/2011), revealed PI # 1 had no documented skin breakdown on her (PI # 1) left below the knee amputation site or right lower posterior leg, and a lack of consistent documentation of PI # 1's daily skin assessments and wound assessment by the nursing staff. As a result, two hospital acquired pressure ulcers were not documented until 12/8/2011. The pressure ulcer on PI # 1's Left Below the Knee Amputation was necrotic when identified and documented by the Certified Ostomy Wound Nurse. A second hospital acquired pressure ulcer, was also identified and documented on PI #1's Right Posterior Lower Leg on 12/8/2011.

This deficient practice affected Patient Identifier (PI #1), one of ten sampled patients.

Findings Include:

Medical Record Review:
According to the History and Physical dated 11/19/2011 and Discharge Summary from the preceding hospitalization (11/8/2011 through 11/18/2011) PI # 1's diagnoses and history includes:
1. Chronic Pyelonephritis with a history of nephrectomy on the left side due to carcinoma of the kidney.
2. End-stage renal disease (on hemodialysis).
3. Type 2 Diabetes Mellitis, uncontrolled.
4. Coronary Atherosclerosis.
5. Peripheral Vascular Disease with amputation above the knee on the left.
6. Escherichia coli infection, recurring in type, causing pyelonephritis.

PI # 1's history also documents Dementia, morbid obesity and poor eyesight.

Documentation by Employee Identifier (EI) # 1, RN, Certified Wound Ostomy Nurse, includes:
Date: 11/18/2011
1) Location: Right Flank
Wound Type: Partial Thickness / Deep Tissue Injury
Stage: Partial Thickness
Acquired at Facility: No

2) Location: Right Inner Thigh
Wound Type: Pressure Ulcer
Stage: Stage 2
Acquired at Facility: No

3) Location: Bilateral Buttock
Wound Type: Pressure Ulcer
Stage: See note
Acquired at Facility: No
Notes: Left buttock 2 x 2.5 centimeters
(suspected deep tissue injury);
Bilateral buttocks old healed pressure ulcers.

4) Location: Left Posterior Thigh
Wound Type: Pressure Ulcer
Stage: Suspected Deep Tissue Injury
Acquired at Facility: No

5) Location: Left Ear
Wound Type: Pressure Ulcer
Stage: Suspected Deep Tissue Injury
Acquired at Facility: No

11/22/2011:
5) Location: Left Ear - Resolved

12/2/2011:
1) Location: Right Flank - Resolved

2) Location: Right Inner Thigh
Wound Type: Pressure Ulcer
Acquired at Facility: No
Wound Status: Not Healed
Stage: Stage 2

3) Location: Bilateral Buttock
Wound Type: Pressure Ulcer
Acquired at Facility: No
Wound Status: Not Healed
Stage: Not documented
Notes: Previous Ulcerations Denuded

4) Location: Left Posterior Thigh
Wound Status: Resolved

5) Location: Right Abdomen (Surgical
Wound- Nephrectomy)
Wound Status: Not Resolved

6) Location: Left Breast
Wound Type: Skin Tear
Acquired at Facility: No
Wound Status: Not Resolved

12/8/2011:
2) Location: Right Inner Thigh
Wound Type: Pressure Ulcer
Acquired at Facility: No
Wound Status: Not Healed
Stage: Stage 2

3) Location: Bilateral Buttock
Wound Type: Pressure Ulcer
Acquired at Facility: No
Wound Status: Not Healed
Stage: Stage 2

4) Location: Right Abdomen (Right Upper
Quadrant -Surgical Wound- Nephrectomy)
Wound Status: Not Healed
Stage: Full Thickness

7) Location: Left Breast
Wound Type: Skin Tear
Wound Status: Resolved

8) Location: Left Below Knee Amputation (BKA)
Wound Type: Pressure Ulcer
Acquired at Facility: Yes
Date Acquired: 12/8/2011
Wound Status: Necrotic (Unstageable)

9) Location: Right Posterior Lower Leg
Wound Type: Pressure Ulcer
Acquired at Facility: Yes
Date Acquired: 12/8/2011
Stage: Suspected Deep Tissue Injury

10) Location: Left Buttock
Wound Type: Skin Tear
Acquired at Facility: No
Wound Status: Not Healed

12/30/2011:
8) Location: Left Below Knee Amputation (BKA)
Wound Type: Pressure Ulcer
Acquired at Facility: Yes
Date Acquired: 12/8/2011
Wound Status: Not Healed
Stage: Stage 4
Exposed Structures: Bone

9) Location: Right Posterior Lower Leg
Wound Type: Pressure Ulcer
Acquired at Facility: Yes
Date Acquired: 12/8/2011
Wound Status: Not Healed
Stage: Stage 2

A review of PI # 1's Interdisciplinary Plan of Care reveals no care plan (no goal, no interventions) are documented regarding PI # 1's "Skin Integrity."

Interviews:

During an interview on 2/2/2012 at 10:40 AM, Employee Identifier (EI) # 1, RN/Certified Wound Ostomy Nurse (CWON), stated she completes a head to toe skin assessment on admission and weekly for all patients. The staff RN's are expected to assess the patient's skin on admission and daily. The staff RN's are also responsible for notifying the CWON of any new concerns or changes that develop. "They (staff RN's) are responsible for dressing changes in between times that I (CWON) see the patient."
According to EI # 1 (CWON), PI # 1's Left Below the Knee Amputation site "looked good" and was intact on admission. On 12/8/2011, EI # 1 reported she noticed an area of necrosis on PI # 1's left below the knee amputation site and stated she was, "Very distressed." EI # 1 stated she was not notified of any changes to PI # 1's skin between her assessment on 12/2/2011 and 12/8/2011. The wound depth was one centimeter. EI # 1 reports she identified a second pressure ulcer on the back of PI # 1's right lower leg on 12/8/2011.
According to EI # 1/RN (CWON), PI # 1's pressure ulcer to the left below the knee amputation site was, "Much deeper, " on 12/22/2011. On 12/30/2011, bone was exposed. EI # 1 stated there was not much protective tissue at the amputation site to begin with.

During a second interview on 2/3/2012 at 2:30 PM, Employee Identifier (EI) # 1, RN/Certified Wound Ostomy Nurse (CWON), stated the staff nurses do not measure or stage pressure ulcers/wounds. The nurses should report changes in a patient's skin and/or wound to the CWON.

During an interview on 2/3/2012 at 11:30 AM, EI # 2/Nurse Manager, stated the wound care nurse places the orders for wound care on the clip board of the nurse who is to provide care to the patient. The staff nurses provide wound care when wound care is not provided by the wound care nurse (provides weekly). The staff nurse is to document the wound assessment on the flow sheet.

During an interview on 2/3/2012 at 3:00 PM, a Staff RN, Employee Identifier (EI) # 5, one of the nurses assigned to care for PI # 1 on 12/6/2011, was asked about the lack of documentation on 12/6/2011 regarding the PI # 1's skin and wounds. EI # 5 stated, "If I didn't document, I didn't see or do it. "

According to the National pressure Ulcer Advisory Panel's Statement on Pressure Ulcer Prevention,(1992), Documentation must be done at regular intervals and should include risk assessment, skin evaluation, therapies designed to maintain intact skin, patient response to alterations in therapy, the rational for the alteration(s) and the outcome of the skin care program.

Policy and Procedure:
A review of the Hospital's Policy, Assessment of the Patient, Policy # HD-NUR 401.04, effective 3/1/08, revised 12/1/09 documents, "Plan of Care: The nursing plan of care will be developed by the RN based on the findings of the admission assessment. The nursing plan of care is to be developed by the RN within the first 24 hours of the patient's stay. The plan of care is to be individualized based on the patient's need for nursing care. A nursing plan of care will be initiated by the RN with evaluations, revisions, or updates documented by the RN/LPN on a weekly or more often as needed."