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Based upon record review, observation and interview, the registered nurse failed to supervise and evaluate the care of each patient by failing to ensure a comprehensive nursing assessment of the patient's skin was conducted for 2 of 10 sampled patients resulting in

1) failing to identity three new wounds on a current patient's (Patient #2) left lower extremity and

2) failing to identify skin breakdown to a patient's (Patient #1) sacrum prior to 10/06/15 when the sacral wound had already reached a Stage 3; and failing to identify additional skin breakdown when the patient was transferred to Hospital A on 01/08/16.
Findings:

1. Failing to identity three new wounds on a current patient's (Patient #2) left lower extremity.

Review of policy #PC. 4.1, 5.1, 5.5, 5.6, 6.3 titled "Wound/Skin Care, Prevention of Breakdown" revealed in part:
Procedure: Assessment 1.d. By nursing staff or Wound Care Professional if there is any significant change in skin integrity;
D. Monitoring and Evaluation: 1. Floor staff to monitor and record skin condition issues when providing patient care; 2. Wound Care Professional to monitor and record skin condition issues when providing patient care. 3. Floor staff to follow Wound Care Professional to monitor and record patient compliance to prevention measures. 6. Any significant change in the patient's condition related to skin care management gives rise for reassessment.

Observations on 01/19/16 at 2:30 p.m. of patient #2 revealed the patient was supine on a specialty bed in the Intensive Care Unit. Interview with S4LPN/Wound Care Nurse and S5RN during the observation revealed the patient was receiving wound care to the right below the knee amputation surgical site and the left second toe. Observation of the left lower extremity revealed in addition to the above wounds the patient had wounds to the left metatarsal head first toe, left metatarsal head fifth toe, and the left plantar area of the fourth toe that were not previously identified by nursing staff. Further interview with S5RN during the observation revealed she was assigned the care of patient #2 and when asked if she was aware of the wounds to the patient's left metatarsal head first toe, left metatarsal head fifth toe, and the left plantar area of the fourth toe, she stated "no". Interview with S4LPN/Wound Care Nurse revealed he was not aware there were additional wounds to patient #2's left lower extremity.

After the wounds were brought to the staff's attention, S4LPN/Wound Care Nurse evaluated the wounds and documented for the Left Metatarsal Head that it was an arterial ulcer, not healed, and measured Length 0.78cm, Width 0.84cm, and Depth 0.1. The wound was 76-100% covered with firmly adherent, hard, black eschar. The left metatarsal head fifth was identified as an arterial ulcer measuring Length 2.23cm, Width 3.38cm, and Depth 0.1cm. 76-100% of the wound bed was covered by firmly adherent, hard, black eschar. The left plantar fourth toe was identified as an arterial ulcer measuring Length 1.88cm, Width 1.88, and Depth 0.1cm. 76-100% of the wound bed was covered with firmly adherent, hard, black eschar.

Review of the nursing notes dated 01/19/16 for patient #2 revealed there failed to be documentation by the Registered Nurse the patient had been evaluated and the additional three wounds to the patient's lower left extremity were identified prior the wounds being brought to the nursing staff's attention by the surveyor.

2) Failing to identify skin breakdown to a patient's (Patient #1) sacrum prior to 10/06/15 when the sacral wound had already reached a Stage 3; and failing to identify additional skin breakdown when the patient was transferred to Hospital A on 01/08/16.

Review of policy #PC. 4.1, 5.1, 5.5, 5.6, 6.3 titled "Wound/Skin Care, Prevention of Breakdown" revealed in part:
Procedure: Assessment 1.d. By nursing staff or Wound Care Professional if there is any significant change in skin integrity;
D. Monitoring and Evaluation: 1. Floor staff to monitor and record skin condition issues when providing patient care; 2. Wound Care Professional to monitor and record skin condition issues when providing patient care. 3. Floor staff to follow Wound Care Professional to monitor and record patient compliance to prevention measures. 6. Any significant change in the patient's condition related to skin care management gives rise for reassessment.

Review of patient #1's medical record revealed the patient was admitted to the hospital on 9/18/15 with Chronic Obstructive Pulmonary Disease with acute exacerbation, Ethanol Abuse, and severe protein-calorie malnutrition. On 9/29/15, the patient experienced respiratory distress and was transferred to the Intensive Care Unit. On 10/6/15, S4LPN/Wound Care Nurse documented the patient had an acute sacral pressure ulcer measuring Length 5.96cm, Width 4.37cm, Depth 0.1cm. The wound was obscured by necrosis with the surrounding wound skin color dark red or purple and/or non-blanchable. There failed to be documented evidence the Registered Nurse conducted skin assessments on the patient and identified the patient had skin breakdown on the sacrum prior to 10/06/16 at which time the wound had progressed to a Stage 3 wound with necrosis.

On 01/04/16 the Wound Care Team documented the following wounds on the patient:

1) Stage 4 sacral pressure ulcer: Length 19.65cm Width 20.93cm Depth 1.8cm. Depth description: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures with undermining. The wound had moderate amount of serosanguineous drainage.

2) Right heel arterial ulcer: Length 4.55cm Length 4.37cm Depth 0.1cm covered by eschar.

3) Left lower leg arterial ulcer: Length 17.51cm Width 17.3cm Depth 0.1cm covered by eschar

4) Left lateral mid foot arterial ulcer: Length 8.88cm Width 7.83cm Depth 0.1cm covered by eschar

5) Right medial ankle arterial ulcer: Length 4.13cm Width 4.11cm Depth 0.2cm covered with eschar

6) Left medial ankle arterial ulcer: Length 5.29cm Width 4.8cm Depth 0.1 covered with eschar

7) Right medial mid foot arterial ulcer: Length 6.29cm Width 5.56cm Depth 0.1cm covered by eschar

8) Left great toe arterial ulcer: Length 2.24cm Width 8.6cm Depth 0.1cm covered by eschar.

The Wound Care Team treatment notes dated 1/4/16 revealed identified wounds to the right heel and left knee where the wound care team were to obtain wound photos and measurements; however, there failed to be documentation these wounds were measured or photographed. Prior wound treatment records also identified the patient had an ulcer to the penis which was not identified on discharge.

On 01/08/15, the shift assessment conducted by the Registered Nurse revealed the following documentation "...PEG tube noted and clamped...Dressing noted to sacrum, CDI (Clean, Dry, Intact) Dressing noted to BLE (Bilateral Lower Extremities) CDI, Dressing noted to penis CDI". Patient #1 was transferred to Hospital A on 01/08/16 at 12:35 p.m.

Review of patient #1's medical record from Hospital A at the time of admission on 01/08/16 revealed the Wound Care Nurse from Hospital A identified the following wounds:
1) Right lower arm with 4cm x 2cm wound with yellow slough
2) Left arm with 0.5cm x 1cm wound with yellow slough;
3) Peg tube to mid abdomen with yellow pus;
4) Left side of penis with 1.5cm x 2 cm perforation, foley catheter seen through site, yellow drainage noted;
5) Left groin with small scab;
6) Right second and third toe webbed. Right second toe with 2 small areas of eschar;
7) Right great toe with 1cm x1cm eschar to tip;
8) Right lateral foot with 6cm x 8.5cm dark brown eschar;
9) Right lower leg and ankle with 20cm x 5 cm 100% dark brown eschar;
10) Right lateral foot with 6cm x 8.5cm dark brown eschar;
11) Right posterior heel with 5cm x 4cm dark brown eschar;
12) Right malleous 1cm x1cm dark brown eschar;
13) Right medial ankle with 5 cm x5cm dark brown eschar with bone exposed;
14) Right medial foot with 1.5cm x 2cm dark brown eschar;
15) Left great toe 8cm x 5cm 100% black eschar, cold to touch;
16) Left second and third toes webbed with 2.2cm x 1cm dark brown eschar;
17) Left small toe with 2cm x 1.5cm dark brown toe;
18) Left medial ankle with 6.5cm x5.5 cm dark brown eschar;
19) Left medial foot near ankle with 3cm x 1 cm dark brown eschar;
20) Left heel with 7cm x 21 cm to left lateral lower leg with dark brown eschar;
21) Left lateral leg with 19.5cm x 7cm dark brown eschar;
22) Left knee with 14.5cm x 10cm dark brown eschar;
23) Left lateral knee with 4cm x 4cm dark brown eschar;
24) Left hip with 4.5cm 1cm wound with yellow center;
25) Right posterior hip with two 0.5cm wounds;
26) Sacrum with 16cm x16cm ulcer with pink wound bed, yellow slough throughout small amount of bone exposed and yellow perimeter;
27) Left isheum with 7cm x 10cm ulcer with pink wound bed and yellow slough;
28) Right ischeum with 7cm x 4cm ulcer with pink wound bed and yellow slough.

Of the 28 wounds identified by the Wound Care Nurse at Hospital A, only 8 of the wounds were identified by Promise Hospital nursing staff when patient #1 was transferred on 01/08/16.

Based on record review, observation and interview, the hospital failed to ensure each patient had an individualized nursing care plan developed that included interventions for all diagnoses for which the patient was being treated for 3 (#1, #4, #9) of 7 patient records reviewed for nursing care plans from a total sample of 10 patients. Findings:

Review of the hospital policy titled Interdisciplinary Treatment Planning, revised 03/15 revealed in part: Planned patient care shall be performed in a coordinated interdisciplinary manner by all patient care managers/disciplines upon admission and continued throughout the patient ' s hospitalization.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 12/28/15 for wound care to the right below the knee surgical site. Further review of the medical record revealed there failed to be a nursing care plan developed related to skin care. On 1/19/16 at 2:30 p.m. observations of the patient revealed the patient had developed two additional wounds to the left lower extremity that were not identified. Interview with S4LPN/Wound Care Nurse revealed the Wound Care Team develop the nursing care plan related to wounds and this information was maintained on the computer.

Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital on 12/22/15 with diagnoses of Pulmonary Edema, Congestive Heart Failure, End Stage Renal Disease, Peripheral Vascular Disease, Diabetes, and a Diabetic ulcer to right lateral foot, S/P Right 5th toe amputation. Review of the Physicians Orders dated 12/22/15 revealed consults for Physical Therapy, Occupational Therapy, and Wound Care. Review of the Wound Care Assessment dated 12/23/15 revealed a skin tear to the left upper extremity with orders for wound care every Monday and Thursday and PRN (as needed). Further review revealed no documented evidence that a nursing care plan was developed for wound care.
Interview on 01/19/15 at 1:45 p.m. with S8RN (Registered Nurse) stated that the patient's care plan was updated each week at staffing. She further stated that the nurse receiving the order for wound care should have updated the care plan at that time.
Interview on 01/19/16 at 2:00 p.m. with S9RN House Supervisor confirmed Patient #4's medical record had no documented evidence of a care plan being developed and implemented for wound care.

Patient #9
Review of Patient #9's medical record revealed she was admitted on 01/15/16. Review of the Interdisciplinary Admission Assessment- Nursing form dated 01/15/16 documented burn areas to buttocks, upper and lower extremities. Review of the Wound Care Assessment dated 01/16/16 revealed a non-healed burn area to the sacrum. Further review revealed no documented evidence that a nursing care plan was developed for wound care.
Interview on 01/20/16 at 9:15 a.m. with S3RN/QAIC confirmed that there was no documented evidence of a care plan being developed and implemented for wound care.

Based on observation and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by failing to ensure proper hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring for 2 of 2 finger sticks observed.

Findings:

Observation on 01/20/16 at11:00 a.m. revealed a finger stick on Patient #7 performed by S10RN (Registered Nurse). S10RN with gloved hands placed a case containing the blood glucose machine on the bed side table. Removing the blood glucose machine from the case S10RN performed the finger stick. S10RN removed her gloves and placed the blood glucose machine back into the case and walked to the nurse's station. Opening the case S10RN then removed the blood glucose machine and wiped it with an alcohol prep and placed the machine back into the case. S10RN then picked up the case and walked down the hall to Patient #9's room. She placed the case on a chair in the room. S10RN then donned gloves and picked up the blood glucose machine from the case and performed the finger stick on Patient #9. S10RN without removing her gloves opened an alcohol prep and wiped the blood glucose machine off before returning the machine to the case. S10RN then removed her gloves and picked up the case and walked to the nurse's station and placed the case on the counter and then proceeded to wash her hands at the sink.

In an interview on 01/21/16 at 3:10 p.m. with S3RN/QAIC stated that all nurses should be using proper hand hygiene with patient care. She further stated that all nurses are in serviced upon hire and annually for all infection control policies.

Interview on 01/20/16 at 1:00 p.m. with S2DON confirmed the nurse should have removed her dirty gloves after patient care and before cleaning the blood glucose machine and placing the machine back into the case. S2DON further stated that the nurses should be performing and maintaining proper hand hygiene between patient care.