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Based on record review and interview, the facility failed to ensure nursing services provided treatment as ordered to 3 of 10 patients (#1, #2, #8) and ensure complete documentation in 4 of 10 plans of care reviewed (#1, #2, #4, #8).

Findings:

Nursing staff failed to administer wound treatment to patients as ordered in 3 of 10 patients reviewed. See tag A392.

Nursing staff failed to document progress toward wound care goals, modifications in goals and/or interventions with changes in wound status and the resolution status of goals at the time of discharge in the IPOC for 4 of 10 patients reviewed. See tag A396.

The cumulative effect of these deficiencies has potentially contributed to worsened wound status in 3 patients with the potential to affect all 31 patients receiving care at this facility at the time of the survey.

Based on record review and interview, nursing staff failed to file an occurance report per policy for 2 of 3 patients with hospital acquired pressure ulcers (#1, #2,).

Findings:

Facility policy "Prevention Skin Integrity and Pressure Ulcer Prevention" states: "2. Licensed Nurse Responsibilities: ...c) If new skin/wound problems are found during the skin integrity check, the nurse will initiate a treatment plan for the wound/skin problem, notify the Wound Care specialist and complete and Occurrence Report for Hospital Acquired Pressure Ulcers."

Pt. #1 was admitted to the facility on 6/8/2015. The admission nursing assessment, dated 6/8/2015, documents "maceration" (softening or breakdown of skin due to moisture) at Pt. #1's coccyx area. An RN progress note dated 6/26/2015 states: "Pt. has a skin tear on right buttock approximately the size of a dime, was cleaned and foam boarder applied [WOCN] notified." The Daily Nursing Assessment dated 7/1/2015 states: "small open area left buttock." On 7/2/2015, the nursing assessment notes the wound with sanginous (bloody) drainage. On 7/4/2015 "Pt. has a dime size stage 2 wound on right buttock." The daily nursing assessment documents Pt. #1's coccyx wound with various amounts of sanginous to serosanginous drainage daily through the time of discharge on 7/18/2015.

On 7/18/2015, WOCN notes include documentation of bilateral ear wounds classified as "pressure" in etiology. The right ear is measured at 3 cm x 2 cm with depth "obscured by necrosis" and "25%-50% wound covered" in necrotic tissue type of "loosely adherent yellow slough." The left ear wound is measured at 2 cm x 1.5 cm with 75%-100% of wound covered with "adherent, soft, black eschar" (dead tissue). There is no previous documentation in the nursing assessment notes or WOCN assessment notes of impaired skin integrity to the ears.

Pt. #2 was admitted to the facility on 6/19/2015. Per the WOCN skin assessment dated 6/19/2015, Pt. #2 had a Stage 1 pressure ulcer on the coccyx area with no open areas at the time of admission. On 6/29/2015 the wound was opened and classified as a stage 2 pressure ulcer.

Review of the facility adverse events/occurance log does not include documentation for change in skin assessment/worsening of wound status for Pt. #1 and Pt. #2.

During an interview with Dir B on 8/18/2015 at 3:30 PM, Dir B stated that adverse events are "followed up by department managers" and then reported to the Performance Improvement and Safety Committee. Dir B stated the majority of incidents are related to medication and B was not aware of "many or any at all" incidents of hospital aquired pressure ulcers.

Based on record review and interview, nursing staff failed to administer wound treatment to patients as ordered in 3 of 10 patients reviewed (#1, #2, #8 ). This deficiency has potentially contributed to worsened wound status in 3 of 3 patients with the potential to affect all 31 patients receiving care at this facility at the time of the survey.

Findings:

Facility policy "Skincare Prevention" states: "1. Wound Care Protocol Scale -- Risk of Skin Breakdown is completed at time of admission for each patient...6-12 = high risk...3. High Risk (6-12 on Wound Care Protocol Scale) A. Skin Hygiene and Inspection: Refer to wound care nurse; ...B. Activity/Mobility: Establish and record and individualized turning schedule if the patient is immobile. Frequency of position change is titrated for the individual patient...C. Skin Protection...Apply skin sealant under adhesves, around ears to protect from oxygen tubing irritation and over bony prominences to reduce friction; Institute measures to contain fecal and/or urinary incontinence (i.e. indwelling or external catheter, fecal incontinence collector) and to protect the skin from incontinence..."

Facility policy "Pressure Relief" states: "1. Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours...A written schedule for systematically turning and repositioning the individual should be used."

Facility policy "Prevention Skin Integrity and Pressure Ulcer Prevention" states: "A. Pressure Ulcer Assessment--to be completed within 4 hours of admission and every shift...B. Roles and Responsibilities of Clinical Staff 1. Wound Care Specialist: a) Performs a complete skin and wound assesment on all new admissions and supervises/ensures implementation of interventions. b) Monitors ongoing skin integrity assessments and the effectiveness of preventive and treatment interventions...2. Licensed Nurse Responsibilities: ...b) Completes skin integrity checks...The nurse does not have to remove dressings or perform wound measurements. The nurse only confirms that a wound exists and that documentation and treatments have been established. c) If new skin/wound problems are found during the skin integrity check, the nurse will initiate a treatment plan for the wound/skin problem, notify the Wound Care specialist and complete and Occurrence Report for Hospital Acquired Pressure Ulcers."

Pt. #1 was admitted to the facility on 6/8/2015. The admission nursing assessment, dated 6/8/2015, documents "maceration" (softening or breakdown of skin due to moisture) at Pt. #1's coccyx area. An RN progress note dated 6/26/2015 states: "Pt. has a skin tear on right buttock approximately the size of a dime, was cleaned and foam boarder applied [WOCN] notified." The Daily Nursing Assessment dated 7/1/2015 states: "small open area left buttock." On 7/2/2015, the nursing assessment notes the wound with sanginous (bloody) drainage. On 7/4/2015 "Pt. has a dime size stage 2 wound on right buttock." The daily nursing assessment documents Pt. #1's coccyx wound with various amounts of sanginous to serosanginous drainage daily through the time of discharge on 7/18/2015.

Per facility policy, the WOCN assesses each patient weekly. The Braden scale (risk assessments for skin breakdown) for Pt. #1 is rated by the WOCN as a "9" (very high risk) on 6/9/2015, 6/16/2015, 6/23/2015, 6/30/2015, 7/6/2015 and 7/14/2015. The initial wound assessment on 6/9/2015 documents the sacrum/coccyx area as a "rash" meauring 10 cm x 5 cm with a BWAT (wound classification) score of 17. Subsequent weekly assessments are documented by the WOCN as follows: 6/16/2015--"continue with miconazle as ordered and monitor," 10 cm x 5 cm with BWAT of 19; 6/23/2015--"continue with miconazle as ordered and monitor," 10 cm x 5 cm with BWAT of 19;
6/30/2015--"continue with miconazle as ordered and monitor," 10 cm x 5 cm with BWAT of 19;
7/6/2015--"continue with miconazle as ordered and monitor," 10 cm x 5 cm with BWAT of 19; 7/14/2015--"1 hour side to side only turn; foam dressing with honey and monitor, also has abrasions on right buttock/gluteal fold and linear [sic] between coccyx [MD] aware," 3 cm x 3 cm x 0.2 cm with BWAT score of 24." Per the WOCN's documentation, Pt. #1's coccyx pressure ulcer remained a reddened "rash" type area of 10 cm x 5 cm until the 7/14/2015 assessment, at which time it progressed to an open ulcer. The RN nursing assessments first document a change in the wound on 6/26/2015 which is not reflected in the WOCN's assessments on 6/30/2015 or 7/6/2015.

Orders to turn patient every 2 hours, apply barrier cream every 6 hours and as needed and apply miconazole (antifungal) powder to coccyx areas of redness every 6 hours are obtained on 6/9/2015. On 7/14/2015 Pt. #1's MR contains orders for "1 hour side to side only turns" and honey gel covered by foam dressing to coccyx every 3 day changes and as needed.

Pt. #1's treatment record includes "apply barrier cream with incontinence cares or as needed" on 6/9/2015 through 7/18/2015. Per the treatment record, Pt. #1 did not receive 43 of 156 prescribed doses of barrier cream from 6/9/2015 through 7/18/2015, with no additional applications with incontinence. Per Pt. #1's MR, Pt. #1 was incontinent of stool 1 to 7 times daily.

The treatment record documents honey gel and foam dressing application on 7/14/2015. Per Pt. #1's treatment record, the dressing is due to be changed on 7/17/2015 and "PRN" (as needed). The dressing change and honey application was not administered until 7/18/2015.

The treatment record does not include any documentation of the ordered miconazole cream.

During an interview on 8/18/2015 at 12:00 PM, CNO C stated all wound-related orders "should be" included on the treatment sheet and confirmed they are not typically listed in other places within the MR, such as in the MAR (medication administration record). There is no evidence in the MR that Pt. #1 received any doses of miconazole powder as prescribed during Pt. #1's inpatient stay at the facility.

Per CNO C, daily turning schedules are used to document the times and positions in which patients are repositioned. A sampling of Pt. #1's turning log reveals Pt. #1 was not repositioned every 2 hours daily through 7/14/2015 or every 1 hour from 7/14/2015 through 7/18/2015 as ordered. On 6/30/2015 Pt. #1 was positioned on the right side at 2:00 PM and repositioned to the left side 6 hours later, at 8:00 PM. On 7/3/2015 Pt. #1 was positioned on the right side at 8:00 AM, "up in chair" 5 hours later at 1:00 PM and then repositioned on the left side 7 hours later at 8:00 PM. On 7/5/2015, Pt. #1 is documented as lying supine at 12:00 AM with no further documentation of position change through 7:00 AM. On 7/9/2015, Pt. #1 is documented as lying supine at 6:00 PM until repositioned 8 hours later on 7/10/2015 at 2:00 AM. On 7/17/2015, Pt. #1 is documented as being repositioned every 2 hours with a left, right, supine position despite orders for every 1 hour side to side only turning.

On 7/18/2015, WOCN notes include documentation of bilateral ear wounds classified as "pressure" in etiology. The right ear is measured at 3 cm x 2 cm with depth "obscured by necrosis" and "25%-50% wound covered" in necrotic tissue type of "loosely adherent yellow slough." The left ear wound is measured at 2 cm x 1.5 cm with 75%-100% of wound covered with "adherent, soft, black eschar" (dead tissue). The BWAT score is documented as 34 for the right ear and 35 for the left ear. There is no previous documentation in the nursing assessment notes or WOCN assessment notes of impaired skin integrity to the ears.

Pt. #2 was admitted to the facility on 6/19/2015 with respiratory failure. Per the WOCN skin assessment dated 6/19/2015, Pt. #2 had a Stage 1 pressure ulcer on the coccyx area with no open areas at the time of admission. Pt. #2's weekly skin assessment is rated "11--high risk" for skin breakdown. Pt. #2's MR contains orders dated 6/19/2015 to apply large foam dressing with every 3 day dressing changes and as needed to the coccyx area; miconazole powder to the coccyx areas of redness every 6 hours and barrier cream every 6 hours and as needed.

Per Pt. #2's treatment record, the coccyx site dressing was changed on 6/25/2015 and next on 7/1/2015, 6 days later. The dressing was changed on 7/18/2015 and next on 7/23/2015, 5 days later. The treatment record does not include miconazole powder.

On 6/29/2015 Pt. #2's wound was opened and classified as a stage 2 pressure ulcer.

Pt. #8 received inpatient services from 5/27/2015 through 7/21/2015. Pt. #8 was documented as having a pressure ulcer on the coccyx area and right heel and a right forearm skin tear upon admission. Orders dated 5/27/2015 state "turn patient every 2 hours." A sampling of Pt. #8's turning log reveals Pt. #8 was not repositioned every 2 hours daily through 7/21/2015 as ordered.

The right forearm skin tear is documented as "healed" on 6/12/2015. On 7/13/2015, the WOCN assessment states the right forearm skin tear is a stage 2 wound measuring 2 cm x 2 cm. On 7/20/2015 a stage 2 pressure ulcer is documented on the right hip measuring 2 cm x 7 cm x 0.1 cm. There is no previous documentation in the nursing assessment notes or WOCN assessment notes of impaired skin integrity to the hip.

During an interview with CNO C on 8/18/2015 at 12:00 PM, CNO C stated all wound-related prevention measures "should be" documented on the patient's treatment sheets. C stated the turning logs were a recently implemented, but staff "should be documenting every time a patient is turned."

Based on record review and interview, facility staff failed to document progress toward wound care goals, modifications in goals and/or interventions with changes in wound status and the resolution status of goals at the time of discharge in the IPOC for 4 of 10 patients reviewed (#1, #2, #4, #8).

Findings:

Facility policy "Plan of Care" states "The care plan for each individual patient shall be coordinated with his/her medical provider plan of care and will indicate what nursing care is needed and how it can be best achieved using evidenced based practice...The care plan will include the identified patient problems, the goals to work toward, and the interventions to be used...The plan of care will be reviewed and updated daily if needed by the RN."

Pt. #1 received inpatient services from 6/8/2015 through 7/18/2015 for respiratory failure. Pt. #1 was non-verbal and immobile throughout the hospitalization.

The admission nursing assessment, dated 6/8/2015, documents "maceration" (softening or breakdown of skin due to moisture) at Pt. #1's coccyx area. An RN progress note dated 6/26/2015 states: "Pt. has a skin tear on right buttock approximately the size of a dime, was cleaned and foam boarder applied [wound RN] notified." The Daily Nursing Assessment dated 7/1/2015 states: "small open area left buttock." On 7/2/2015, the nursing assessment notes the wound with sanginous (bloody) drainage. On 7/4/2015 "Pt. has a dime size stage 2 wound on right buttock." The daily nursing assessment documents Pt. #1's coccyx wound with various amounts of sanginous to serosanginous drainage daily through the time of discharge on 7/18/2015.

Per facility policy, the wound RN assesses each patient weekly. The Braden scale (risk assessments for skin breakdown) for Pt. #1 is rated by the wound RN as a "9" (very high risk) on 6/9/2015, 6/16/2015, 6/23/2015, 6/30/2015, 7/6/2015 and 7/14/2015.

Pt. #1's "Interdisciplinary Plan of Care" (IPOC) dated 6/30/2015 includes a problem/focus area of "Impaired skin integrity related to rash" with goals of "Wound will improve during hospitalization as evidenced by: Decrease in size of wounds as noted in weekly assessments; no further skin breakdown." Interventions include: "Wound care per orders; Reposition every 1-2 hours and PRN; Keep skin clean and dry with incontinence/barrier products; Specialty mattress; Heel elevation boots while in bed; Educate patient/family/caregiver on causes of pressure ulcer development and strategies to improve healing; Assess skin each shift and PRN." Weekly review of progress toward goal attainment on 7/1/2015 states: "wounds healing" and "goals unchanged." Weekly review dated 7/14/2015 states: "no new wounds" and "goals unchanged." The IPOC also contains a problem/focus area of "High risk for Impaired Skin Integrity due to immobility" with a goal of "Patient will be free of skin breakdown." There is no documentation of weekly progress toward goal included in the IPOC.

Weekly IDT conference notes do not include documentation of pressure ulcer status on 6/10/2015, 6/17/2015, 6/24/2015 and 7/1/2015. On 7/8/2015 wound care status notes "perirectal area improving" with a goal to "improve wound healing." On 7/15/2015 the wound care discipline section notes "Pressure ulcer(s): 2" and the prioritized list of goals for the week documents: "wounds will improve by decrease in size."

Pt. #1's IPOC does not include any modifications to the goals or interventions to reflect the change in Pt. #1's wound status during the hospitalization. There is no documentation of the resolution of goals at the time of Pt. #1's discharge on 7/18/2015.

Pt. #2 was admitted to the facility on 6/19/2015 with respiratory failure. Per the WOCN skin assessment dated 6/19/2015, Pt. #2 had a Stage 1 pressure ulcer on the coccyx area with no open areas at the time of admission. Pt. #2's IPOC includes a problem/focus area of "Impaired skin integrity related to rash" with goals of "Wound will improve during hospitalization as evidenced by: Decrease in size of wounds as noted in weekly assessments; no further skin breakdown." Interventions include: "Wound care per orders; Reposition every 1-2 hours and PRN; Keep skin clean and dry with incontinence/barrier products; Specialty mattress; Heel elevation boots while in bed; Educate patient/family/caregiver on causes of pressure ulcer development and strategies to improve healing; Assess skin each shift and PRN." Weekly review of progress toward goal attainment on 7/1/2015 states: "wound size less" and "goals unchanged." Weekly review dated 7/14/2015 states: "no new wounds" and "goals unchanged." The IPOC also contains a problem/focus area of "High risk for Impaired Skin Integrity due to immobility" with a goal of "Patient will be free of skin breakdown." There is no documentation of weekly progress toward goal included in the IPOC.

On 6/29/2015 the wound was opened and classified as a stage 2 pressure ulcer. Pt. #2's IPOC does not include any modifications to the goals or interventions to reflect the change in Pt. #2's wound status during the hospitalization. There is no documentation of the resolution of goals at the time of Pt. #2's discharge on 8/1/2015.

Pt. #4 received inpatient services at the facility from 7/8/2015 through 7/29/2015 for respiratory failure status post cardiac arrest. The weekly Braden scale assessment for Pt. #4 is rated 10-12 "high risk" for skin breakdown. Pt. #4's IPOC, dated 7/8/2015, contains a problem/focus area of "High risk for Impaired Skin Integrity due to immobility, altered level of consciousness and incontinence" with a goal of "Patient will be free of skin breakdown." There is no documentation of weekly progress toward goal included in the IPOC.

Initial and daily nursing assessments 7/8/2015 through 7/15/2015 document normal skin assessments with no signs of pressure ulcers. On 7/16/2015, erythema (redness) is noted at the coccyx area. Redness and drainage is documented through 7/24/2015. Pt. #4's IPOC does not include any modifications to the goals or interventions to reflect the change in Pt. #4's skin status during the hospitalization. There is no documentation of the resolution of goals at the time of Pt. #4's discharge on 7/29/2015.

Pt. #8 received inpatient services from 5/27/2015 through 7/21/2015. Pt. #8 was documented as having a pressure ulcer on the coccyx area and right heel and a right forearm skin tear upon admission. Pt. #8's IPOC includes a problem/focus area of "Impaired skin integrity related to pressure ulcer" with goals of "Wound will improve during hospitalization as evidenced by: Decrease in size of wounds as noted in weekly assessments; no further skin breakdown." Interventions include: "Wound care per orders; Reposition every 1-2 hours and PRN; Keep skin clean and dry with incontinence/barrier products; Specialty mattress; Heel elevation boots while in bed; Educate patient/family/caregiver on causes of pressure ulcer development and strategies to improve healing; Assess skin each shift and PRN." Weekly review of progress toward goal attainment on 7/1/2015 states: "no further skin breakdown" and "goals unchanged." Weekly review dated 7/14/2015 states: "no new wounds" and "goals unchanged." The IPOC also contains a problem/focus area of "High risk for Impaired Skin Integrity due to immobility and altered level of conciousness" with a goal of "Patient will be free of skin breakdown." There is no documentation of weekly progress toward goal included in the IPOC.

On 7/20/2015 a stage 2 pressure ulcer is documented on the right hip measuring 2 cm x 7 cm x 0.1 cm. The right forearm skin tear is documented as "healed" on 6/12/2015. On 7/13/2015, the WOCN assessment states the right forearm skin tear is a stage 2 wound measuring 2 cm x 2 cm. Pt. #8's IPOC does not include any modifications to the goals or interventions to reflect the change in Pt. #8's skin status during the hospitalization. There is no documentation of the resolution of goals at the time of Pt. #8's discharge on 7/21/2015.

During an interview with CNO C on 8/18/2015 at 12:00 PM, CNO C stated staff is expected to document patient progress toward goals weekly "unless goals are met", but there is no process in place to document the status of the patient's IPOC goals at the time of discharge.