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Based on interviews and documentation review, the Hospital failed to ensure that:1) 1 of 11 patients (Patient #1) was properly assessed for safety when outside on Hospital grounds and
2) safety checks were carried out effectively for 2 of 11 patients (Patient #1 and Patient #8).

Findings included:

1) Review of Patient #1's medical record documentation indicated that on 2/25/11 Patient #1 was admitted to the Hospital's Medical/Surgical Unit for medical management and rehabilitation therapies after surgical repair of a fractured hip. Prior to the fracture Patient #1's baseline mobility status was independent use of a motorized wheelchair. Patient #1's diagnoses included: cervical stenosis with residual motor deficits; a history of spinal surgeries; Paranoid Schizophrenia managed on medications; seizure disorder; history of cigarette smoking; coronary artery disease; angina; alcohol/intravenous drug abuse, and Hepatitis C.

Medical record documentation, dated 2/25/11 to 5/10/11, indicated that Patient #1 was noncompliant with the plan of care and refused treatments such as therapy sessions and nutritional supplements. Patient #1 required assistance with care, received physical therapy, and was transferring with supervision. Patient #1 used a manually operated wheelchair independently when out of bed.

Review of medical record documentation indicated that around 3/8/11 Patient #1 began to leave the Unit and go outside on the Hospital grounds to smoke.

Review of the medical record documentation indicated that therapy evaluations and sessions were carried out inside the Hospital and did not include the Hospital grounds.

The Physical Therapist Aide (PTA) assigned to Patient #1 was interviewed on 5/10/11 several times during the survey. The PTA said the assessment process did not include assessing the patient for safe mobility on the Hospital grounds.


2) Review of the Hospital's Policy/Procedure titled Nursing Observation for 15 Minute Checks, effective 7/09, indicated that direct care staff were responsible for the observation of patients on checks and that patients on 15 minute safety checks must be escorted off the Unit by a staff member.

Review of the Medical/Surgical Unit Policies indicated that patients leaving the Unit must sign out/in, patients were not allowed off the Unit before 9:00 A.M. or after 8:00 P.M. patients could only be off the Unit for 30 minutes.

Patient #1:
Review of medical record documentation indicated that on 2/27/11 Patient #1 was placed on 15 minute safety checks.

Review of the 15 minute Nursing Observation Records, dated 3/8/11 to 5/10/11, indicated that Patient #1 was off the Unit for periods of time ranging form 30 minutes to 2 hours.

Observation during a tour of the Medical/Surgical Unit conducted on 5/10/11, indicated that Patient #1 was up in a wheelchair with a coat on and was self propelling unattended of the Unit.

Review of the Sign Out Sheet indicated that Patient #1 did not sign out prior to leaving the Unit.

Review determined that the area designated for patient smoking was located outside behind the Hospital, was not on video surveillance, and was not continuously monitored by a staff member.

Direct care staff who had been assigned to Patient #1 were interviewed as follows: the Nurse Manager was interviewed on 5/10/11 at 8:10 A.M.; Nurse #1 was interviewed on 5/10/11 at 11:10 A.M.; Nurse #2 was interviewed on 5/10/11 at 11:35 A.M.; Nurse #3 was interviewed on 5/10/11 at 12:10 P.M.; Nurse #4 was interviewed on 5/10/11 at 2:40 P.M.; Nurse #5 was interviewed on 5/10 11 at 3:15 P.M.; Nurse Aide #1 was interviewed on 5/10/11 at 12:00 P.M.; Nurse Aide #2 was interviewed on 5/10/11 at 3:05 P.M., and Nurse Aide #3 was interviewed on 5/10/11 at 3:25 P.M.

Interviews indicated that Patient #1 was not escorted and 15 minute checks were not carried out when Patient #1 was off the Unit.

Review of Incident Reports related to Patient #1 indicated that there was no incidents that occurred while Patient #1 was off the Unit.

Patient #8:
Review of medical record documentation indicated that Patient #8 was admitted to the Hospital on 4/28/11. Patient #8 was his/her own responsible party. Patient #8's medical history was significant for alcoholism, and bilateral lower extremity leg ulcers. Patient #1 used a motorized wheelchair for mobility. Patient #8 was placed on 15 minute safety checks.

Review of 15 minute Nursing Observation Records, dated 5/5/11 to 5/10/11, indicated that Patient #8 was off the Unit for periods ranging from 30 minutes to 1.5 hours and was off the Unit after 8:00 P.M. in the evening.

Review of the Sign Out Sheet, from 5/8/11 at 2:00 P.M. until 5/10/11 at 2:00 P.M. indicated that although Patient #8 was off the Unit on 5/8/11 at 5:15 P.M. and 9:00 P.M.; Patient #8 did not sign out when he/she left the Unit and did not sign in when he/she returned to the Unit.

Based on interview, observation, and medical record review, the Hospital failed to ensure that:
1) Skin Risk Assessments were completed and/or were accurate for 2 or 11 patients (Patient #1 and Patient #8);
2) Use of embolitic stockings were appropriately documented for 1 of 11 patients (Patient #1) and changes in skin status were identified in a timely manner;
3) Pressure ulcers were appropriately measured per policy or that the Wound Consultant was notified of pressure ulcer development/deterioration in a timely manner for 1 of 11 patients (Patient #1), and
4) the correct pressure relieving device was used for 1 of 11 patients (Patient #1).

Findings included:

1) Review of the Hospital's Policy/Procedure titled Pressure Ulcer Prevention and Treatment Protocols indicated that A Braden Skin Risk Assessment was completed for all patients on admission. Braden Assessments were completed weekly if the patient was at moderate risk or greater on admission and if there was any significant change in condition (such as with a surgical procedure, transfer, and with care plan update.

Review of the Braden Skin Risk Assessment indicated that it was located in the electronic medical record and was completed by the nurses. The level of risk for skin breakdown was based on the nurse's assessment of the patient's score in the following areas: moisture; sensory perception; activity; mobility; nutrition, and friction/shear. The score for each area was totaled and based on the total score, the patient was leveled at low, moderate, or high risk for skin breakdown.

Patient #1:
Review of Patient #1's medical record documentation indicated that on 2/25/11 Patient #1 was admitted to the Hospital's Medical/Surgical Unit after surgical repair of a fractured hip for medical management and rehabilitation therapies. Upon admission Patient #1 was on hip precautions, required moderate assistance with bed mobility and transfers. Patient #1 did not ambulate. A condom catheter (an external catheter) was used to address incontinent episodes.

Review of Patient #1's admission Braden Assessment indicated that it was incorrectly scored in activity (Patient #1 was scored as walks frequently) and in mobility (Patient #1 was scored as no limitations). As a result Patient #1's total score indicated that Patient #1 had no risk for skin breakdown.

Review of medical record documentation indicated that on 3/3/11 Patient #1 was found to have suspected deep tissue injuries to both heels and a Stage II pressure ulcer on the right side of the coccyx. Patient #1 then developed another pressure ulcer that progressed to a Stage IV.

Review of the Braden Assessments provided by the Hospital and completed for Patient #1 indicated that a Braden Assessment was not completed when pressure ulcers were first identified on 3/3/11 and were not completed until 4/1/11. Braden Assessments were completed per policy thereafter.

Patient #8:

Observation of Patient #8 during a tour of the Medical/Surgical Nursing Unit conducted on 5/10/11 indicated that Patient #8 was obese and had bilateral bilateral feet and ankle ulcers. Patient #8 was on a pressure reduction mattress and had a motorized wheelchair with a pressure relieving cushion in it.

Review of Patient #8's medical record documentation indicated that Patient #8 was admitted to the Hospital on 4/28/11 and had a history of cellulitis. The ulcers were present on admission and were being treated. Documentation indicated that otherwise Patient #8's skin was intact. Patient #8 was assisted with turning and repositioning and was repositioned regularly.

Review of information provided by the Hospital indicated that a Braden Skin Risk Assessment had never been completed for Patient #8.


2) Review of the Admission Orders, Admission History and Physical, Admission Nursing Assessment, dated 2/25/11, indicated that upon admission Patient #1's skin was intact other than the surgical incision from the fractured hip repair. Lovenox (anticoagulant to prevent blood clot formation) was ordered daily to prevent deep vein thrombosis (DVT) prophylaxis.

Physician documentation, dated 2/26/11 to 3/2/11, indicated that DVT prophylaxis interventions included Lovenox. There were no other interventions documented.

Nursing documentation, dated 2/26/11 to 3/2/11, indicated that Patient #1's skin was intact other than the surgical incision from the fractured hip repair.

A Nursing Note, dated 3/2/11, indicated that Patient #1 had embolitic stockings (TEDS) on and the lower extremities were noted to be "puffy".

Review of medical record documentation indicated that on 3/3/11 the TEDS were removed by the Physical Therapist Aide (PTA) to assess lower extremity edema. Patient #1 was identified with suspected deep tissue injuries to both heels.

The Director of Inpatient Services was interviewed intermittently throughout the survey. The Director said if TEDS were in use then there should be a physician order and use of TEDS should be addressed in the medical record.


3) Review of medical record documentation indicated that on 3/3/11 Patient #1 was found to have a Stage II pressure ulcer on the right side of the coccyx. The Wound Consultant (the Director of Clinical Practice) was notified.

The Wound Management Consultation Report, dated 3/4/11, indicated that Patient #1 had a 4 centimeter (cm) x 3.5 cm Stage II pressure ulcer on the coccyx area toward the right hip. Treatment recommendations were cleanse with normal saline, apply moisture barrier cream, and cover with Foam AG with adhesive dressing. The dressing was to be changed every 72 hours (every 3 days) and as needed. An air mattress was ordered.

The Director of Clinical Practice was interviewed intermittently throughout the survey. The Director said the pressure ulcer on the coccyx area was small and superficial.

The Hospital's Policy/Procedure titled Pressure Ulcer Prevention and Treatment Protocols indicated that pressure ulcers must be assessed with each dressing change and measured weekly. Findings were to be documented.

Review of the electronic documentation regarding Wound Assessments and Nursing Progress Notes, dated 3/4/11 to 3/23/11, indicated the following:
> on 3/7/11 Patient #1's buttocks were noted with black burnt-like skin with the left area of the coccyx pilled and beefy red.
> on 3/8/11 the pressure ulcer appeared to be extending. The wound in the coccyx area was closer to the left buttock, was red, and was larger in size measuring 6 cm x 6 cm. There was a new partially thick opening 3 cm x 1 cm closer to the right buttock red with some yellow in the wound bed. Below the open areas was a new large black area 8 cm x 6 cm with a blister now starting to peel off. Treatments were done as ordered.
> on 3/10/11 the right buttocks was pink and the left buttocks pressure ulcer was blackened.
> on 3/12/11 the right buttock wound was pink and the left buttock wound was necrotic with foul-smelling wound bed.
> on 3/14/11 the dressing were changed but there was no description or measurement.
> on 3/15/11 documentation indicated the black under the pressure ulcers was resolved. Dressings were applied to each buttock.
> on 3/16/11 documentation indicated the right buttock pressure ulcer was pink and healing. The left buttock pressure ulcer was pink at the edges with brown tissue in the middle.
> on 3/19/11 and 3/20/11 the buttock pressure ulcers were unchanged from 3/16/11.
>on 3/21/11 the dressing was changed and dark yellow slough was present in the pressure ulcer.

Nursing documentation, dated 3/23/11, indicated that the Director of Clinical Practice was notified of the pressure ulcer. The original pressure ulcer was healed and the pressure ulcer, located on the left buttock measuring 8.6 x 5.4 x 2.7 cm, covered with black necrotic tissue, and was unstagable. Treatments were ordered.

The Director of Clinical Practice said she was not notified of the change or deterioration in the pressure ulcer until 3/23/11. The Director said the original pressure ulcer had healed. The Director said after she evaluated the left buttock pressure ulcer, an appropriate treatment was ordered. The Director said she continued to closely monitor Patient #1 and the buttock pressure ulcer was much improved as of the survey.

Review of the documentation indicated that the pressure ulcers were not measure weekly per policy and there was no evidence that there was communication about Patient #1's status until 3/23/11.



4) The Physical Therapist Aide (PTA) assigned to Patient #1 was interviewed on 5/10/11 several times during the survey. The PTA said Patient #1 was supposed to be on a Roho cushion (an air-filled pressure relieving cushion) when out of bed in the wheelchair.

Review of Physical Therapy documentation indicated that Patient #1 was supposed to be on the Roho cushion when out of bed in the wheelchair.

A tour of the Medical/Surgical Unit was conducted on 5/10/11 with the Director of Inpatient Services and the Risk Manager present. During the tour Patient #1 was observed to be seated in the wheelchair. Patient #1 was observed to be seated on a gel cushion with an incontinence pad folded in half over it. Patient #1 left the Unit to go out on the Hospital grounds.

Patient #1 was later observed to be on the correct pressure relieving device.

Based on interview and documentation review the Hospital failed to ensure that the plan of care was updated for 1 of 11 patients (Patient #1).

Findings included:

1) Please refer to Standard A-0144 for background information.

Review of the Care Plan indicated that 15 minute checks and off Unit privileges were not addressed in the Care Plan.

2) Review of medical record documentation indicated that on 3/3/11 Patient #1 was found to have suspected deep tissue injuries to both heels and a Stage II pressure ulcer on the right side of the coccyx. A wound and nutrition consult were obtained. Orders for pressure relief, wound treatments, and nutritional support were recommended and ordered.

Review of the Care Plan indicated that it was not updated to include the pressure ulcers or interventions implemented.

3) Review of medical record documentation, dated 2/25/11 to 5/10/11, indicated that Patient
#1 was noncompliant with: 1) participating in rehabilitation therapy sessions; 2) drinking the nutritional supplement ordered to assist in wound healing (occasionally refused); 3) the Unit policy for signing out when leaving the Unit; 4) the 30 minute limit for off Unit privileges, and 5) the recommended limited time out of bed to promote pressure ulcer healing.

Documentation also indicated that Patient #1 had a wound vacuum in place to drain a Stage IV pressure ulcer which Patient #1 had disconnected on at least one occasion in order to get out of bed.

Review of the Care Plan indicated that Patient #1's behaviors and noncompliance were not addressed.

Based on documentation review, the Hospital failed to ensure that all documentation related to Advanced Directives was accurate for 1 of 11 patients (Patient #1).

Findings included:

Review of the Face sheet, dated 2/25/11, indicated that a female was listed as Patient #1's Health Care Agent (HCA; makes decisions regarding care when the patient is no longer capable).

Review of medical record documentation indicated that the Hospital used an Advanced Directive Checklist upon admission to determine if a patient had an Advanced Directive, if a copy of the Directive was placed in the medical record, or if the patients wished to and/or were able to formulate a Directive.

Review of Patient #1's medical record indicated that on 2/26/11 an Advance Directive Checklist was completed. The Checklist indicated that Patient #1's Guardian (not the person listed on the face sheet) was also the Health Care Agent (HCA).

The Checklist was not checked off to indicate a copy of the Health Care Proxy was placed in the medical record and review of the medical record indicated a copy was not in place.

Review of the Guardianship documentation in the medical record indicated that the Guardian was authorized to manage Patient #1's antipsychotic medications and ranges until the next scheduled hearing on 8/16/11. The Guardianship did not indicate that the Guardian was authorized to act as Patient #1's HCA.

A medical student note, dated 3/10/11, indicated that Patient #1 as well as his/her HCA (not the Guardian) gave consent for a vaccination.

It was unclear as to whether other documentation was available through the Guardian or was maintained at Patient #1's group residence to indicate the Guardian was also the HCA.

Based on interviews and documentation review the Hospital failed to identify all opportunities for improvement during its investigation of Patient #1's pressure ulcer.

Findings included:

Please refer to Standard A-0395 for background information.

The Hospital reported that after Patient #1's pressure ulcer was evaluated by the Director of Clinical Practice on 3/23/11, it was reported to administration and an investigation was conducted.

The Director of Clinical Practice, the Medical/Surgical Unit Nurse Manager, and the Nurse Educator were interviewed intermittently throughout the survey and regarding the investigation and corrective actions.

Interviews and review of the Investigation determined the following were identified:
1) Nursing staff were noncompliant with the requirements of the Pressure Ulcer Prevention and Treatment Policy.
2) There was a lack of accountability among the nursing staff. Treatments were done by different nurses and it was not until one nurse did the treatment several times when the status change was communicated.
3) There was insufficient hand-off communication between nursing, the medical staff, and the Director of Clinical Practice regarding the change of status with Patient #1's buttock ulcers.
4) Medical record documentation was insufficient by the Medical staff.
5) The Pressure Ulcer Prevention and Treatments Policy needed to be revised.
6) Patient #1 was noncompliant with the plan of care increasing the risk for skin breakdown and there was no evidence of patient teaching regarding the consequences.

The Hospital did not address/identify the following during its investigation:
1) The Braden Skin Risk Assessment completed on admission was inaccurate.
2) The development of the suspected deep tissue injuries to the bilateral heels (identified on 3/3/11) or the circumstances surrounding their development
3) The Care Plan was not updated in a timely manner (when pressure ulcers were identified on 3/3/11) and did not address Patient #1's behavioral concerns and noncompliance.

Based on interviews and documentation review the Hospital failed to ensure that all corrective actions were identified in response to the investigation or were implemented at the time of the survey.

Findings included:

The Director of Clinical Practice, the Medical/Surgical Unit Nurse Manager, and the Nurse Educator were interviewed intermittently throughout the survey and regarding the investigation and corrective actions.

Interviews and review of the Corrective Action Plan indicated that the following were identified:
1) Revision of the Pressure Ulcer Prevention and Treatment Policy. The revised Policy was in draft form at the time of the survey.
2) Review of the Hand-off Communication and Pressure Ulcer Prevention and Treatment Protocols with nursing and medical staff. The Director of Clinical Practice said she met with staff on the Medical/Surgical Unit and verbally discussed the Pressure Ulcer Prevention Policy. As of the survey formal re-education had not been implemented.
3) Create a guide (Wound Board) for nurses to follow patients with actual/potential skin breakdown to ensure compliance with the Policy. Not developed or implemented at the time of the survey.


The Corrective Action Plan indicated that documentation by the medical staff would be ongoing but did not indicate if the medical staff would be re-educated regarding the requirements.