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Based on review of medical records, facility policy and procedure and interview with Employee Identifier (EI) # 1, the Chief Nursing Officer, it was determined the facility failed to follow their policy for restraints. The facility failed to assess patients for the need for use of restraints and document appropriate orders for restraints. This had the potential to affect all patients served by this facility and did affect 2 of 3 medical records reviewed with restraints. This affected Medical Record (MR) # 4 and # 2.


Findings include:

Policy: Restraint and Seclusion

V. Policy:
A. There are two types of restraint recognized at ...: non behavioral health restraint (acute medical/ surgical) and emergency behavior management restraint.
B. Restraint will be implemented in the least restrictive manner.
C. The use of restraint/seclusion will be addressed in the patient's plan of care and/or treatment plan and updated/ revised as indicated.
VII. Restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use.

VI. Procedures
B. Physician's Orders

4. Orders for restraint/seclusion must contain the following elements:
A. Date and time
B. Reason for restraint/seclusion
C. Type of restraint/seclusion to be used
D. Duration (time limit) for restraint
E. If verbal order, signature of RN ( registered nurse) writing order
F. Physician signature, date and time

5. The time limits for restraint and seclusion orders are as follows:
A. For acute medical/surgical restraint- up to 24 hours.

9. When the original order is about to expire, an RN can report to the physician the results of the most recent assessment and request a renewal of the original order for another period of time... A face to face evaluation by an LIP ( licensed independent practitioner) must occur... and once each calendar day for non-behavioral ( acute medical-surgical) restraint.


Medical Record Findings


1. MR # 4 was admitted to the hospital on 3/26/11 with a complaint of abdominal pain. The patient was discharged 4/19/11 and had the following diagnoses Perforated Diverticulum with Intra-abdominal Abscess, status post Exploratory Laparotomy with Colostomy, Left Lower Lobe Pneumonia, Bipolar Disorder with Episodes of Psychosis and altered mental status in the hospital... and Surgical Abdominal Wound, which will heal by secondary intention.

On 3/29/11 the physician documented in the progress notes, " Confused, combative. Requiring restraints and sedation."

An order was written 3/29/11 at 20:00 for restraint to protect essential lines/ equipment/ tubes, protect interference with treatment and to promote medical healing. The type of restraint was marked for vest, wrist, 2 pt (point), 4 pt, soft for a duration of 24 hours.

An order was written for restraint on 3/30/11, 4/1/11, 4/2/11, 4/3/11, 4/4/11, 4/5/11, 4/6/11, 4/7/11, 4/8/11, 4/9/11, 4/10/11, 4/11/11, 4/12/11, 4/13/11 and 4/14/11 to continue 24 hours.

A restraint initiation and reassessment was entered on the patient 3/31/11, 4/1/11, 4/2/11, 4/4/11, 4/5/11, 4/6/11, 4/7/11, 4/8/11, 4/9/11, 4/10/11, 4/11/11, 4/12/11, 4/13/11 and 4/14/11. There was no documentation of a reassessment made of the patient 4/3/11.

On 4/16/11 at 03:00 a telephone order was written by a nurse( initials), " Give extra 20 mg ( milligrams) Geodon IM ( intramuscular) x 1. Apply 4 point restraint." This order failed to follow the policy by including a time limit, type of restraint, reason for restraint/seclusion, Physician signature, date and time and the signature of the RN.

The restraint ongoing monitoring form for 4/16/11 at 5:58 AM, documented restraint activity: on, observed behavior: calm, can't follow instructions, restraint applied to: arm, left, arm, right.

This was the only documentation the surveyor observed in the medical record reviewed for 4/16/11 regarding the use of the restraint. The order failed to follow the policy for writing telephone orders, the order was not properly signed by the Registered Nurse or co-signed by the physician and there was no documentation of a reassessment of the patient.

2. MR # 2 was admitted to the hospital on 2/25/11 with complaints of weakness, confusion and elevated calcium level. The patient experienced a rapid mental and physical decline and became obtunded. The patient was discharged to a rehabilitation hospital 4/14/11 with discharge diagnoses including Respiratory Failure, Metabolic Encephalopathy, Severe Hypercalcemia, Hypertensive Cardiovascular Disease, Urinary Tract Infection and Protein Calorie Malnutrition.

The patient had a restraint order dated 2/28/11. The type of restraint was wrist, 2 pt(point), 4 pt, soft, duration 24 hours, time of order 20:00. The next orders for this patient were 3/1/11 and 3/2/11 with information including time, duration and type.
The restraint order written 3/3/11, 3/4/11, 3/13/11 failed to include a time and a duration of use on the orders.
The restraint order written 3/7/11 and 3/8/11 failed to include a time the order was written.
The restraint order written 3/12/11 failed to include a time,a duration of use and the type of restraint to be used on the orders.


On 4/29/11 at 12:30 PM, in response to written questions, EI # 1, the Chief Nursing Officer, provided orders for restraints that had failed to print with the other documents and confirmed this was the orders for the use of the restraints.

Based on review of medical records, review of policies and procedures, interview with staff nurses, Employee Identifier (EI) # 2 and # 3 and the Chief Nursing Officer, EI # 1, it was determined the facility failed to provide nursing care as ordered to 3 of 3 patients reviewed with wounds. The nurse failed to document assessment, size, location, drainage, type of wound and the wound care provided. The nurses also failed to follow the physician's orders for wound care. This affected Medical Record(MR) # 1, # 2 and # 4.
Findings include:
Policy and Procedure- Skin Integrity: Skin Assessment, Risk Assessment, Preventing Loss of Skin Integrity
I. Purpose:
The purpose of this policy is to identify patients at risk for loss of skin integrity, identify patients who have loss of skin integrity, and to provide guidelines and protocols to maintain patients ' skin integrity.
V. Policy Statement: Routine skin assessments will be performed on all hospitalized patients upon admission and upon the initial assessment by each new caregiver. Any loss of skin integrity noted by a PCT (patient care technician) or other staff member will be reported to patient ' s primary nurse. The nurse will assess patient ' s risk for loss of skin integrity by using the Braden scale. The nurse will initiate the Standing Orders to Maintain Skin Integrity for each patient who is at risk for skin breakdown. The nurse will initiate wound or skin care for any loss of skin integrity by using the Wound and Skin Care Standing Orders.
VI. Procedure: Skin assessment of all skin folds for rash and breakdown. Assess the skin on the pressure points ...
C. Based on patient ' s Braden score and individualized assessment, the primary nurse will institute a plan of care and Standing Orders to Maintain Skin Integrity.
D. Documentation of existing wounds, other loss of skin integrity will be in the electronic chart. The staff nurse will implement skin care/wound care via the Standing Orders for Skin and Wound Care to maintain a moist wound environment and promote healing.

Policy and Procedure- Wound Care: Care of the Patient with Loss of Skin Integrity, Skin Care and Wound Care
I. Purpose: The purpose of this policy is to provide a plan of care for a patient whose skin assessment reveals abnormalities.
VI. Procedure:

A. The patient ' s primary nurse will institute the appropriate wound care protocols when a skin abnormality is discovered. The protocol will be chosen based on the appearance of the wound as well as its location and history.
B. The licensed nurse will differentiate between the different types of loss of skin integrity. He/she will document the appearance of the skin/loss of skin integrity.
C. The nurse will document the following in the electronic chart:

Type of classification:
Cause of wound if possible such as surgical or skin tear Superficial, partial thickness, full thickness, pressure ulcer, and moisture associated dermatitis.
Location
Size: if able length x width x depth in cm (centimeters)
(6-12 o ' clock, 3-9 o ' clock) Also note tunneling/ undermining
Wound Bed: color, presence of bone, tendon, slough, eschar , sutures, granulation tissue, etc.
Exudates: amount, type, color
Odor: If present
Surrounding skin: intact, ulcerations, maceration, rash
Wound Edges: rolled over or closed, " open " - even flush with the wound base.
Signs/Symptoms of Infection: Induration, erythema, increase in pain
Pain: change in pain. Increase pain in a wound can indicate an infection ...
Co morbidities: Diabetes, COPD (chronic obstructive pulmonary disease), cardiovascular history, CHF (congestive heart failure), bariatric.

1. MR # 1 was admitted to the hospital on 3/22/11 with a diagnosis of Abdominal Pain.
On 3/23/11 the patient underwent a sigmoid colon resection with colostomy and Hartmann ' s pouch formation. The surgeon also completed a small bowel resection with primary anastomosis and a repair of a bladder fistula.

A review of the physician progress notes revealed the following information. On 4/4/11 a second abdominal surgery was performed. On 4/8/11 the patient was intubated and placed back in Intensive Care Unit on a ventilator. The patient was extubated 4/14/11. The patient returned to the general floor on telemetry 4/17/11.
The progress note dated 4/19/11 was the first documentation of a decubitus ulcer by the physician.
An order was written 4/20/11 for a wound care consult.
The CWOCN (Certified Wound Ostomy Continence Nurse) consult to assess pressure ulcer and colostomy was completed 4/20/11. The CWOCN documented, " Pt (patient) with pressure ulcer to left buttock 6 cm x 3 cm x .1 cm pink 75% beige 25% with no drainage. Coccyx stage II 1 cm x 4 cm x .1 cm with no drainage pink. Recommend 4 x 4 Mepilex adhesive foam dressing 2 x a week, cover both ulcers. Noted open stage II to labia .4 cm x .3 cm x .1 cm dry, recommend Sensicare cream bid (twice a day). Pt is on a First Step mattress which provides pressure reduction. "

The wound care orders written 4/20/11 were for the following wound care: Wound care left buttock and coccyx, clean with Saf Cleans wound cleanser, apply skin protection barrier, wipe to surrounding skin. Apply 4 x 4 of Mepilex adhesive foam dressing 2 x a week. Apply Sensicare to labia 2 x a day and leave open to air.
The integumentary assessment documented in the electronic record from 3/22/11 documented skin warm and dry, intact. On 4/8/11 the integumentary assessment documented under skin integrity not intact. The nurse documented 4/8/11 at 20:18, " Location- Buttocks. Right buttock small area noted to what appears to be friction related. Will apply mepilex dressing. "
The nurse did not have an order on the medical record for the use of Mepliex, did not notify the physician or any other nurse the patient had an open area to her right buttock.

On 4/29/11 at 7:40 AM the surveyor interviewed Employee Identifier (EI) # 2, the Registered Nurse who had provided the wound care 4/8/11. When asked if she reported the skin breakdown to anyone, EI # 2 replied, " In report. " The surveyor asked if she had reported the skin breakdown to the physician or told the daughter who was staying with the patient. EI # 2 stated that the patient was aware she put a dressing on her buttock. MR # 1 was intubated and on the ventilator 4/8/11.

The next documented skin assessment was 4/12/11 which had skin integrity as intact. The skin integrity was documented as intact 4/13/11, 4/14/11, 4/15/11, 4/16/11.

On the skin assessment of 4/18/11 at 15:00 pressure ulcer of the buttocks was documented with wound care provided of cleansing with wound care spray, Saf Clens, apply wound gel and Mepilex dressing. On 4/18/11 at 16:00 skin assessment, " Skin warm, dry, intact. No rashes, lesion, pressure area." On 4/18/11 at 19:00 skin symptoms- ulcers/lesions, no comment of a dressing being present. On 4/18/11 at 19:30- pressure ulcer, buttocks, dressing dry and intact- Mepilex. The assessments on 4/18/11 vary, wound care was provided but no documentation of notifying the physician or where the order for the Mepilex came from.

On the skin assessment 4/19/11 at 08:00- ulcers/lesions and 4/19/11 at 20:00- ulcers/lesions. A note was added to the 4/19/11 08:00, " to sacral area- not assessed- mirapex (Mepilex) in place- dry and intact." There was no order for the Mepilex at this time in the medical record and no documentation of who applied the Mepilex.
The 4/20/11 at 07:00 skin symptoms- ulcers/lesions and 4/20/11 at 20:00 skin symptoms- ulcers/lesions. There was no documentation of a dressing being in place even though the CWOCN had assessed the patient at 18:10 and provided a dressing with Mepilex. The 4/21/11 at 07:00 skin symptoms- ulcers/lesions and 4/21/11 at 20:00 skin symptoms- ulcers/lesions. There was no documentation of a dressing being in place.
On 4/22/11 at 08:00 the skin assessment documented skin integrity intact. The CWOCN visited with the patient at 12:30 on 4/22/11 and documented, " Buttock Mepilex dressing change by nurse prior to my visit and is intact." There was no documentation in the medical record the nurse had changed the dressing. There was no documentation since 4/20/11 by the CWOCN of the appearance, drainage, odor, size or signs/symptoms of infection in the medical record.
The patient was discharged to a rehabilitation hospital 4/22/11. An addition to the discharge order was added 4/22/11 at 11:30 AM, " Continue wound packing BID with 4 x 4 x 12 gauze."
On 4/28/11 at 2:50 PM the surveyor interviewed EI # 3, staff nurse, regarding the last order the physician had documented concerning packing a wound. EI # 3 explained the physician was removing the staples and a small part of the incision opened up and he wanted it packed every day. EI # 3 also stated that he did not remove any more of the staples after that.The surveyor asked EI # 3, if she performed the wound care to the patient's buttocks on 4/22/11. EI # 3 stated that she did provide wound care to the area on the buttocks and described it to me as, " More of a large area in the center with some light yellow tissue in one area but it looked clean, I put Mepilex on it."
There was no documentation of the incision line opening in the medical record, no documentation of any staples being removed or any documentation of a wound being packed and dressed.
On 4/29/11 at 12:30 PM, in response to written questions, EI # 1, the Chief Nursing Officer, confirmed the above information.

2. MR # 2 was admitted to the hospital on 2/25/11 with complaints of weakness, confusion and elevated calcium level. The patient experienced a rapid mental and physical decline and became obtunded. The patient was discharged to a rehabilitation hospital 4/14/11 with discharge diagnoses including Respiratory Failure, Metabolic Encephalopathy, Severe Hypercalcemia, Hypertensive Cardiovascular Disease, Urinary Tract Infection and Protein Calorie Malnutrition.

On the admission skin assessment 2/25/11 the skin was intact no decubiti present.
On 3/13/11 the Plan of Care Update form documented as a problem, " Immobility needing support surface/bed."
On 3/29/11 an order was written for Resinol PRN ( as needed).
On 3/30/11 the Plan of Care Update form documented that patient was on an air mattress and cream applied to buttocks. The skin assessment from 3/30/11 on the nurses assessment through discharge 4/14/11 failed to document any skin breakdown or rashes. The documentation consistently was skin intact.
On 4/29/11 at 12:30 PM, in response to written questions, EI # 1, the Chief Nursing Officer confirmed the order for Resinol and that she understood the patient probably had a rash but it was not documented.

3. MR # 4 was admitted to the hospital on 3/26/11 with a complaint of abdominal pain. The patient was discharged 4/19/11 and had the following diagnoses Perforated Diverticulum with Intra-abdominal Abscess, status post Exploratory Laparotomy with Colostomy, Left Lower Lobe Pneumonia, Bipolar Disorder with Episodes of Psychosis and altered mental status in the hospital... and Surgical Abdominal Wound, which will heal by secondary intention.

Patient History from physician's progress notes and orders:
The patient underwent surgery 3/30/11, an exploratory laparotomy with Hartmann's procedure.
On 4/1/11 the surgeon's progress note documented, " Will start wound dressing changes."
The physician's orders for 4/1/11 documented, " Begin Q( every) 12 h(hour)dressing change with Betadine solution wet-to-dry with 4 x 4 gauze."
On 4/2/11 and 4/3/11 the surgeon's progress note documented, " Abd(abdomen) bandaged, ostomy- pink/viable."
On 4/2/11 the physician's orders included, " Air mattress."
On 4/4/11 the surgeon's progress note documented, " Wound inspected- clean."
On 4/6/11 the surgeon's progress note documented, " Wound inspected- clean."
On 4/8/11 the surgeon's progress note documented, " Wound - clean continue dressing changes."
On 4/9/11 the surgeon's progress note documented, " Open wound- packed."
On 4/13/11 the physician ordered, " Consult Enterostomal Specialist."
On 4/16/11 the surgeon's progress note documented, " Wound same- fairly clean- needs continued wound care- orders written."
On 4/16/11 the physician ordered, " Ask...(CWCON) to see her regarding colostomy management. Continue dressing changes as presently done to do after D/C( discharge) BID."
On 4/18/11 the surgeon's progress notes documented, " Wound- looks better since saline overnight."

On 4/18/11 the physician ordered, " Be sure wound care consult called in as requested by Dr... 4/16. Family/patient need education/ training for wound care and colostomy care."
On 4/19/11 the patient was discharged home with Home Health for wound care and ostomy care. The discharge orders for 4/19/11 were, " Wound care- change BID use Betadine QAM soaked/ packed with sterile pads and bandaged. QPM- use Saline for same procedure."

On 3/30/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline- dressing intact drainage present 4 x 4's gauze dressing and micropore." There was no description of the drainage or the amount on the dressing.

On 3/30/11 at 20:00 the skin assessment documented Incision/ wound # 2, " Surgical incision, abdomen left- dry, intact, 4 x 4's, micropore, petroleum gauze."

On 3/31/11 the skin assessment form at 08:00 did not mention wounds or incision lines.

On 3/31/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline- drainage present 4 x 4's and micropore." There was no description of the drainage or the amount on the dressing.

On 4/1/11 the skin assessment form at 08:00 did not mention wounds or incision lines.

On 4/1/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline- retention suture, dressing dry, intact." The wound appearance on the clinical documented the wound appearance as, " Open." There was no measurement of the open area and no documentation any wound care was provided.

On 4/2/11 at 18:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline- retention suture." The wound appearance on the clinical note documented the wound appearance as, " Open." There was no measurement of the open area. The wound care which is ordered every 12 hours was only documented one time 4/2/11.

On 4/3/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline- staples." The wound appearance on the clinical document has the wound appearance as, "Gaping open." There was no measurement of the open area. The wound care which is ordered every 12 hours was only documented one time 4/3/11.

On 4/4/11 at 08:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline-retention suture, packed open with sterile dressing, wound edges well defined, wet to dry dressing." There was no documentation of what the wet to dry dressing was moistened with or if the wound had any drainage, odor or signs of infection.

On 4/4/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline- dry intact 4 x 4's." The wound care which is ordered every 12 hours was only documented one time 4/4/11.

On 4/5/11 the skin assessment form at 08:00 did not mention wounds or incision lines.

On 4/5/11 at 17:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline-retention suture, dressing changed, packed open with sterile dressing, serosanguineous drainage, changed steri-strips." There was no documentation of a wet to dry dressing being applied or how much drainage was present, measurement, odor or signs of infection.

On 4/5/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline-retention suture, packed open with sterile dressing, dressing dry, intact." This was documented 3 hours after the dressing change prior to this. There was no documentation of a wet to dry dressing being applied or how much drainage was present, measurement, odor or signs of infection.

On 4/6/11 the skin assessment form at 08:00 did not mention wounds or incision lines.

On 4/6/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline-retention suture, dressing- dressing dry, intact 4 x 4's, wet to dry dressing." There was no documentation of what the wet to dry dressing was moistened with or if the wound had been changed or drainage, odor or signs of infection.

On 4/7/11 at 5:39 on the clinical documents wound care was documented as changed, the wound appearance as, " Stained open." There was no measurement of the open area. The wound care which is ordered every 12 hours was only documented one time 4/7/11.

On 4/8/11 at 07:45 the skin assessment documented Incision/ wound # 1, " Fissure, abdominal midline-retention suture, description- gaping,wound edges poorly defined, cleaned with Sterile Saline- 4 x 4's, gauze dressing, light packing." There was no documentation of a wet to dry dressing being applied as ordered or if the wound had any drainage, odor or signs of infection.

On 4/8/11 the skin assessment form at 20:00 did not mention wounds or incision lines. The wound care which is ordered every 12 hours was only documented one time 4/8/11.

On 4/9/11 at 07:45 the skin assessment documented Incision/ wound # 1, " Surgical incision, abdominal midline-retention suture, dressing dry, intact ." There was no documentation of a dressing change being performed or assessment of drainage, odor or signs of infection.

On 4/9/11 at 18:09 on the clinical documents wound care was documented as changed, the wound appearance as, " Gaping open." There was no measurement of the open area or if the wound had any drainage, odor or signs of infection.

On 4/10/11 the skin assessment form at 08:00 did not mention wounds or incision lines. The wound care which is ordered every 12 hours was only documented one time 4/10/11.

On 4/10/11 at 20:00 the skin assessment documented Incision/ wound # 1, "Surgical incision, abdominal midline-retention suture, description- edematous, edges approximated, granulated, improving, cleaned with soap and water wet to dry dressing." There was no documentation of what type of wet to dry dressing was applied or if the wound had any drainage, odor or signs of infection. There was no order to clean the surgical incision with soap and water.

On 4/11/11 the skin assessment form at 07:00 did not mention wounds or incision lines.

On 4/11/11 at 20:00 the skin assessment documented Incision/ wound # 1, "Surgical incision, abdominal midline-retention suture, dressing dry, intact, 4 x 4 's, silk tape. The wound care which is ordered every 12 hours was not documented as done on 4/11/11. The orders were not followed.

On 4/12/11 at 20:00 the skin assessment documented Incision/ wound # 1, "Surgical incision, abdominal midline-retention suture, dressing dry, intact."There was no documentation if wound care was performed. The wound care which is ordered every 12 hours was not documented on 4/12/11.

On 4/13/11 at 04:40 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdominal midline-retention suture, description- granulated,redness, other-open wound, drainage- odor free, irrigated with Sterile Saline-changed 4 x 4's, wet to dry dressing, Telfa island." There was no documentation of what type of wet to dry dressing was applied or if the wound had any drainage or signs of infection.

On 4/13/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdominal midline-retention suture, description- granulated,redness, other-open wound,, cleaned with Chlorhexidine, cleaned with Sterile Water-changed 4 x 4's, silk tape. Other Betadine soaked gauze." There was no documentation if the wound had any drainage, odor or signs of infection. This wound care failed to follow the physician's orders.

On 4/14/11 the skin assessment form at 08:00 did not mention wounds or incision lines.

On 4/14/11 at 17:40 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdominal, description- other surgical dressing, dressing- other surgical dressing." There was no documentation wound care was provided 4/14/11.

On 4/15/11 at 08:00 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdominal, description- Betadine wet to dry, drainage- serosanguineous, dressing- wet to dry dressing, other- Betadine."

On 4/15/11 at 20:00 the skin assessment documented Incision/ wound # 1, " Abscess, abdomen right, description- necrotic tissue, eschar, redness, dressing- wet to dry dressing." There was no documentation of the necrotic tissue or eschar being reported to the surgeon.

On 4/16/11 at 07:30 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdomen midline- dressing- intact." The wound care which is ordered every 12 hours was not documented as done on 4/16/11. The orders were not followed.

On 4/17/11 at 07:40 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdomen midline-other: Saf cleanse, dressing- dry intact. Changed." The wound care which is ordered every 12 hours was not documented as done on 4/17/11. The orders were not followed.

On 4/18/11 the skin assessment form at 08:00 and at 19:45 did not mention wounds or incision lines. The wound care which is ordered every 12 hours was not documented as done on 4/18/11. The orders were not followed.

On 4/19/11 at 08:00 the skin assessment documented Incision/ wound # 1, " Surgical Incision, abdomen, intervention- dressing changed 7 staples removed, description- gaping, redness, stapled, tenderness around wound, tenderness within wound, surrounding tissue- erythema, wound edges well defined, cleaned with Sterile Saline, other Betadine, wet to dry dressing."
The nurses failed to provide the wound care every 12 hours and follow the physician's orders.

On 4/13/11 the physician ordered, " Consult Enterostomal Specialist." On 4/16/11 the physician ordered, " Ask...(CWOCN) to see her regarding colostomy management. Continue dressing changes as presently done to do after D/C( discharge) BID." On 4/18/11 the physician ordered, " Be sure wound care consult called in as requested by Dr... 4/16. Family/patient need education/ training for wound care and colostomy care."

The patient was referred to the CWOCN nurse for wound evaluation and assessment on 4/14/11 and 4/18/11.


There was no documentation in the medical record when reviewed by the surveyor that the CWOCN visited the patient or did teaching to the patient or daughter regarding the ostomy or wound care.

The skilled nurses documentation was inconsistent in the documentation of wound care. The skilled nurses failed to follow the physician's orders and failed to follow the hospital policy related to Care of the Patient with Loss of Skin Integrity, Skin Care and Wound Care.

On 4/29/11 at 12:30 PM, in response to written questions, EI # 1, the Chief Nursing Officer, confirmed the above information.

Based on a review of medical records and interview with the Chief Nursing Officer, Employee Identifier (EI) # 1, it was determined the facility failed to update or revise the nursing care plan with up to date information from ongoing patient assessments. This had the potential to affect all patients served by the facility and did affect Medical Record (MR) # 1, # 3 and # 4.

Findings include:

1. MR # 1 was admitted to the hospital on 3/22/11 with a diagnosis of Abdominal Pain.
On 3/23/11 the patient underwent a sigmoid colon resection with colostomy and Hartmann ' s pouch formation. The surgeon also completed a small bowel resection with primary anastomosis and a repair of a bladder fistula.

A review of the physician progress notes revealed the following information. On 4/4/11 a second abdominal surgery was performed. On 4/8/11 the patient was intubated and placed back in Intensive Care Unit on a ventilator. The patient was extubated 4/14/11. The patient returned to the general floor on telemetry 4/17/11.

The plan of care update dated 3/25/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision, potential/ actual infection
Goal: Incision without drainage,no evidence skin breakdown, no signs/symptoms of infection. Goal met: No."


The plan of care update dated 3/26/11, 3/27/11, 4/7/11, 4/9/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision, potential/actual infection, positioning/ friction issues, nutrition deficiencies. Goal: Improvement of skin lesion/ breakdown, incision approximated,no advancement of Lesion/ breakdown,no evidence of skin breakdown,no sign/ symptoms of infection. Goal met: No."

The plan of care update dated 4/4/11 documented, " Skin/ Mucosal plan of
care update- Problem: Surgical incision, incontinence issues. Goal: Incision approximated, incision without drainage,no advancement of Lesion/ breakdown,no evidence of skin breakdown,no sign/ symptoms of infection. Goal met: No."

The plan of care update dated 4/5/11, 4/6/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision. Goal: Incision approximated. Goal met: No."

The plan of care update dated 4/9/11, 4/10/11, 4/11/11, 4/12/11, 4/14/11, documented, " Skin/ Mucosal plan of care update- Problem: Rash, skin abnormality, potential/actual infection, positioning/ friction issues, incontinence issues, nutrition deficiencies, immobility needing support surface/ bed. Goal: Absence or improvement of rash, improvement of skin lesion/ breakdown, no advancement of lesion/breakdown, no evidence skin breakdown, no signs/symptoms of infection. Goal met: No."

This update did document a problem with friction issues and the patient had wound care performed by a nurse 4/8/11 the day before this update, there was no documentation in the medical record to support any changes made to address the identified problems.

The plan of care update dated 4/16/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision, potential/actual infection, positioning/ friction issues. Goal: Incision approximated, incision without drainage. Goal met: No."

The plan of care update dated 4/17/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision Goal: Incision approximated, incision without drainage, no evidence skin breakdown, no signs/symptoms of infection. Goal met: Yes."

The patient received care for a break in the skin integrity 4/8/11 and 4/18/11 which continued through discharge. The nurses failed to update the plan of care for skin to include the breaks in skin integrity.


2. MR # 4 was admitted to the hospital on 3/26/11 with a complaint of abdominal pain.
The patient was discharged 4/19/11 and had the following diagnoses Perforated Diverticulum with Intra-abdominal Abscess, status post Exploratory Laparotomy with Colostomy, Left Lower Lobe Pneumonia, Bipolar Disorder with Episodes of Psychosis and altered mental status in the hospital... and Surgical Abdominal Wound, which will heal by secondary intention.

The plan of care update dated 3/30/11 documented, " Restraint Plan of Care update- Problem: Dislodgement of life saving tubes/ invasive lines. Goals: No injury or harm related to restraint use, restraints discontinued when alternative measures successful, restraints removed when criteria for removal met." No goal was documented.
On 3/31/11 the same information was documented for the problem and goal. The restraint goal was not met.
The next plan of care update was for 4/3/11 and documented the same information for problem and goal. This update documented the goal was met.
On 4/5/11 the same information was documented for the problem and goal. The restraint goal was not met.
On 4/7/11, 4/12/11, 4/16/11, 4/17/11 the same information was documented for the problem and goal. No goal was documented.
On 4/8/11 the same information was documented for the problem and goal. The restraint goal was not met.
The plan of care continued to address restraints even after the last order for restraints was 4/14/11.
The orders for the restraints continued daily from 3/29/11 through 4/14/11.

The plan of care update which was dated 4/1/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision, potential/ actual infection...
Goal: Incision approximated, incision without drainage, no signs/symptoms of infection. Goal met: Yes."

The next plan of care update was dated 4/3/11, no mention of the skin integrity problem was identified.

The next plan of care update was dated 4/4/11, no mention of the skin integrity problem or restraints was identified.

The plan of care update dated 4/5/11, 4/12/11, 4/16/11, 4/17/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision. Goal: Incision approximated, incision without drainage, no advancement of lesion/ breakdown, no evidence skin breakdown, no signs/symptoms of infection. Goal met: No."

The plan of care update dated 4/7/11, 4/10/11 documented, " Skin/ Mucosal plan of care update- Problem: Surgical incision, potential/ actual infection...
Goal: Incision approximated, incision without drainage, no evidence skin breakdown, no signs/symptoms of infection. Goal met: No."

The next plan of care update was dated 4/8/11, no mention of the skin integrity problem was identified.

The skin/mucosal plan of care update failed to address the wound care ordered every 12 hours and the fact the patient had an opening in the incision line which required packing effective 4/9/11.

3. MR # 3 was admitted to the facility on 3/13/11 for complaint of increasing shortness of breath.

The plan of care update dated 3/29/11 documented, " Skin/ Mucosal plan of care update- Musculoskeletal POC Interventions: Assess for fall risk, implement fall risk protocol as indicated. Documented Progress toward skin goal: Surgical incision is CDI ( clean, dry, intact) free of edema or redness. Dsg( dressing ) changed." The patient had no surgical incision and no dressing change ordered.

The plan of care update dated 4/3/11 documented, " Skin/ Mucosal plan of care update-Problem: Potential/actual infection, positioning/friction issues, nutrition deficiencies, immobility needing support surface/ bed. Progress toward skin goal: surgical incision is CDI, free of edema or redness. Dsg( dressing ) changed Q day." The patient had no surgical incision and no dressing change ordered.

In written questions submitted to Employee Identifier (EI) # 1, the Chief Nursing Officer, on 4/28/11, the surveyor asked if the nurse was to update the plan of care daily as part of the electronic record. On 4/29/11 at 12:45 PM, EI # 1 stated, " Yes."

In response to written questions EI # 1 stated on 4/28/11 at 12:45 PM, MR # 3, did not have a surgical incision the entry was made by mistake.

Based on review of medical records, review of policies and procedures, interview with staff nurses, Employee Identifier (EI) # 2 and # 3 and the Chief Nursing Officer, EI # 1, it was determined the facility failed to provide nursing care as ordered to 3 of 3 patients reviewed with wounds. The nurse failed to document assessment, size, location, drainage, type of wound and the wound care provided. The nurses also failed to follow the physician's orders for wound care. This affected Medical Record(MR) # 1, # 2 and # 4.
Findings include:
Policy and Procedure- Skin Integrity: Skin Assessment, Risk Assessment, Preventing Loss of Skin Integrity
I. Purpose:
The purpose of this policy is to identify patients at risk for loss of skin integrity, identify patients who have loss of skin integrity, and to provide guidelines and protocols to maintain patients ' skin integrity.
V. Policy Statement: Routine skin assessments will be performed on all hospitalized patients upon admission and upon the initial assessment by each new caregiver. Any loss of skin integrity noted by a PCT (patient care technician) or other staff member will be reported to patient ' s primary nurse. The nurse will assess patient ' s risk for loss of skin integrity by using the Braden scale. The nurse will initiate the Standing Orders to Maintain Skin Integrity for each patient who is at risk for skin breakdown. The nurse will initiate wound or skin care for any loss of skin integrity by using the Wound and Skin Care Standing Orders.
VI. Procedure: Skin assessment of all skin folds for rash and breakdown. Assess the skin on the pressure points ...
C. Based on patient ' s Braden score and individualized assessment, the primary nurse will institute a plan of care and Standing Orders to Maintain Skin Integrity.
D. Documentation of existing wounds, other loss of skin integrity will be in the electronic chart. The staff nurse will implement skin care/wound care via the Standing Orders for Skin and Wound Care to maintain a moist wound environment and promote healing.

Policy and Procedure- Wound Care: Care of the Patient with Loss of Skin Integrity, Skin Care and Wound Care
I. Purpose: The purpose of this policy is to provide a plan of care for a patient whose skin assessment reveals abnormalities.
VI. Procedure:

A. The patient ' s primary nurse will institute the appropriate wound care protocols when a skin abnormality is discovered. The protocol will be chosen based on the appearance of the wound as well as its location and history.
B. The licensed nurse will differentiate between the different types of loss of skin integrity. He/she will document the appearance of the skin/loss of skin integrity.
C. The nurse will document the following in the electronic chart:

Type of classification:
Cause of wound if possible such as surgical or skin tear Superficial, partial thickness, full thickness, pressure ulcer, and moisture associated dermatitis.
Location
Size: if able length x width x depth in cm (centimeters)
(6-12 o ' clock, 3-9 o ' clock) Also note tunneling/ undermining
Wound Bed: color, presence of bone, tendon, slough, eschar , sutures, granulation tissue, etc.
Exudates: amount, type, color
Odor: If present
Surrounding skin: intact, ulcerations, maceration, rash
Wound Edges: rolled over or closed, " open " - even flush with the wound base.
Signs/Symptoms of Infection: Induration, erythema, increase in pain
Pain: change in pain. Increase pain in a wound can indicate an infection ...
Co morbidities: Diabetes, COPD (chronic obstructive pulmonary disease), cardiovascular history, CHF (congestive heart failure), bariatric.

1. MR # 1 was admitted to the hospital on 3/22/11 with a diagnosis of Abdominal Pain.
On 3/23/11 the patient underwent a sigmoid colon resection with colostomy and Hartmann ' s pouch formation. The surgeon also completed a small bowel resection with primary anastomosis and a repair of a bladder fistula.

A review of the physician progress notes revealed the following information. On 4/4/11 a second abdominal surgery was performed. On 4/8/11 the patient was intubated and placed back in Intensive Care Unit on a ventilator. The patient was extubated 4/14/11. The patient returned to the general floor on telemetry 4/17/11.
The progress note dated 4/19/11 was the first documentation of a decubitus ulcer by the physician.
An order was written 4/20/11 for a wound care consult.
The CWOCN (Certified Wound Ostomy Continence Nurse) consult to assess pressure ulcer and colostomy was completed 4/20/11. The CWOCN documented, " Pt (patient) with pressure ulcer to left buttock 6 cm x 3 cm x .1 cm pink 75% beige 25% with no drainage. Coccyx stage II 1 cm x 4 cm x .1 cm with no drainage pink. Recommend 4 x 4 Mepilex adhesive foam dressing 2 x a week, cover both ulcers. Noted open stage II to labia .4 cm x .3 cm x .1 cm dry, recommend Sensicare cream bid (twice a day). Pt is on a First Step mattress which provides pressure reduction. "

The wound care orders written 4/20/11 were for the following wound care: Wound care left buttock and coccyx, clean with Saf Cleans wound cleanser, apply skin protection barrier, wipe to surrounding skin. Apply 4 x 4 of Mepilex adhesive foam dressing 2 x a week. Apply Sensicare to labia 2 x a day and leave open to air.
The integumentary assessment documented in the electronic record from 3/22/11 documented skin warm and dry, intact. On 4/8/11 the integumentary assessment documented under skin integrity not intact. The nurse documented 4/8/11 at 20:18, " Location- Buttocks. Right buttock small area noted to what appears to be friction related. Will apply mepilex dressing. "
The nurse did not have an order on the medical record for the use of Mepliex, did not notify the physician or any other nurse the patient had an open area to her right buttock.

On 4/29/11 at 7:40 AM the surveyor interviewed Employee Identifier (EI) # 2, the Registered Nurse who had provided the wound care 4/8/11. When asked if she reported the skin breakdown to anyone, EI # 2 replied, " In report. " The surveyor asked if she had reported the skin breakdown to the physician or told the daughter who was staying with the patient. EI # 2 stated that the patient was aware she put a dressing on her buttock. MR # 1 was intubated and on the ventilator 4/8/11.

The next documented skin assessment was 4/12/11 which had skin integrity as intact. The skin integrity was documented as intact 4/13/11, 4/14/11, 4/15/11, 4/16/11.

On the skin assessment of 4/18/11 at 15:00 pressure ulcer of the buttocks was documented with wound care provided of cleansing with wound care spray, Saf Clens, apply wound gel and Mepilex dressing. On 4/18/11 at 16:00 skin assessment, " Skin warm, dry, intact. No rashes, lesion, pressure area." On 4/18/11 at 19:00 skin symptoms- ulcers/lesions, no comment of a dressing being present. On 4/18/11 at 19:30- pressure ulcer, buttocks, dressing dry and intact- Mepilex. The assessments on 4/18/11 vary, wound care was provided but no documentation of notifying the physician or where the order for the Mepilex came from.

On the skin assessment 4/19/11 at 08:00- ulcers/lesions and 4/19/11 at 20:00- ulcers/lesions. A note was added to the 4/19/11 08:00, " to sacral area- not assessed- mirapex (Mepilex) in place- dry and intact." There was no order for the Mepilex at this time in the medical record and no documentation of who applied the Mepilex.
The 4/20/11 at 07:00 skin symptoms- ulcers/lesions and 4/20/11 at 20:00 skin symptoms- ulcers/lesions. There was no documentation of a dressing being in place even though the CWOCN had assessed the patient at 18:10 and provided a dressing with Mepilex. The 4/21/11 at 07:00 skin symptoms- ulcers/lesions and 4/21/11 at 20:00 skin symptoms- ulcers/lesions. There was no documentation of a dressing being in place.
On 4/22/11 at 08:00 the skin assessment documented skin integrity intact. The CWOCN visited with the patient at 12:30 on 4/22/11 and documented, " Buttock Mepilex dressing change by nurse prior to my visit and is intact." There was no documentation in the medical record the nurse had changed the dressing. There was no