HospitalInspections.org

The registered nurse (RN) failed to supervise and evaluate the care for each patient; the RN administered treatments/medications without orders; the RN failed to photograph wound per policy; the RN failed to perform admission assessments and nutritional screening correctly; the RN failed to perform skin care as ordered; the RN failed to establish regular turning/repositioning schedule for patient as ordered and the RN failed to weigh patients as ordered (See Tag A 395); The nursing staff failed to develop and keep current care plans (See Tag A 396); The Director of Nursing failed to provide for evaluation of clinical activities of non-employee personnel (See Tag A 398); The RN failed to ensure drugs and treatments are provided in accordance with orders of the practitioner (See Tag A 405).

Based on observation and staff interview it was determined the hospital failed to ensure patients' rights to confidentiality of the clinical records. This failure creates the potential for violation of rights for all patients and has the potential to result in unauthorized access to patient information.

Findings include:

1. Observations were conducted on all inpatient units throughout the survey conducted 12/1/14 through 12/4/14. A general trend of failure to maintain confidentiality of clinical records was observed. Examples include:

a. On 12/1/14 the surveyor observed a computer screen with medical record visible in the hallway of the general rehabilitation unit (GRU) at 2:00 p.m. The screen was on the nursing cart in the hallway and no staff were present. The surveyor waited at the cart for approximately three (3) to four (4) minutes until registered nurse (RN) #2 arrived. The nurse was advised to log off the screen before leaving the cart and she indicated she thought she had.

b. On 12/3/14 the surveyor observed a computer screen with patient information visible near the nursing station in the specialty care unit (SCU) at 4:45 p.m.. The screen was on the nursing cart in the hallway and no staff were present. The surveyor waited at the cart for approximately two (2) to three (3) minutes until RN #3 arrived. The nurse was advised to log off the screen before leaving the cart and she stated she had been just around the corner nearby. She then acknowledged she was out of the line of site for the cart and would log off in the future.

c. On 12/4/14 the surveyor observed a laptop computer sitting, partially open, on a cart in the hallway in the GRU at 8:05 a.m.. No staff were present at the cart. The surveyor lifted the screen and patient information was visible. The surveyor waited at the cart for approximately five (5) minutes during which time staff passed in the hallway. The surveyor asked one passing staff member, who was using the laptop. The staff member stated she did not know and went on down the hallway. After approximately seven (7) minutes the surveyor questioned another passing staff member, rehabilitation nursing tech #1, who acknowledged she was using the laptop. She was advised to log off the computer when she left the cart.

d. On 12/4/14 the surveyor observed three (3) sheets of paper, with patient names and assignments and treatments, laying on top of the computerized cart located in the sitting area near the television on the GRU. No staff were present. The surveyor removed these papers and walked through the unit, past the nursing station, unchallenged by staff present.

These patient assignment papers and observations were reviewed and discussed with the Director of Nursing (DON) at 8:30 a.m. on 12/4/14. She acknowledged the staff is responsible to maintain confidentiality of all electronic and paper medical record information at all times. She indicated the failure to log off the screen prior to leaving the cart has been addressed in the past.

Based on review of medical records, review of documents and staff interview it was determined the medical staff failed to demonstrate knowledge and accountability for the quality of care provided to one (1) of one (1) patients reviewed whose care resulted in a physician meeting/review and action plan (patient #1). This failure creates the potential for an adverse impact on the quality of care for all patients.

Findings include:

1. On 11/5/14 the State Agency (SA) received a self-report of acquired wounds which were alleged to have resulted from neglect of patient #1 while she was hospitalized. The hospital reported a thorough investigation into the allegations was being conducted in order to develop action plans to prevent further incidents. The SA conducted a complaint investigation related to these allegations.

Review of the undated investigation and action plan provided by the hospital and interview with the Director of Risk Management on 12/1/14 at 11:30 a.m. revealed areas of deficient practice involving medical staff were identified and addressed. The lack of any wound care orders was one area identified by the hospital during the review of care for patient #1.

The Director of Risk Management stated a meeting was held with all involved medical staff. Review of the attendance for the 11/12/14 physician meeting revealed the Attending Physician was present, although the Medical Director did not attend. The Action Plan for this meeting stated in part: "Wound Protocols need to be written...Ongoing medical staff documentation audits will occur."

2. Interview was conducted with the Attending Physician on 12/3/14 at 10:20 a.m. He was asked about the investigation findings and plan of action. The physician acknowledged he was aware of the investigation into the care of patient #1. He also indicated greater wound surveillance would be conducted in the future. When asked about the hospital's finding that the patient had no wound care orders written, he stated he was unaware there were no wound care orders on this chart.

Based on medical record review, review of documents and staff interview it was determined the medical staff failed to enforce the bylaws and rules and regulations to carry out its responsibilities. This failure was evident in two (2) of ten (10) patients reviewed (patients #1 and 2). This creates a potential for an adverse impact on the quality of medical care for all patients.

Findings include:

1. Review of the medical record for patient #1 revealed nursing documented development of skin breakdown on the left heel on 10/20/14 and coccyx area on 10/24/14.

A summary review of the medical staff progress notes regarding skin revealed the following:

a. No mention of skin breakdown on coccyx area noted until 10/30/14 at 6:26 p.m. when the Physician Assistant (PA) documented in part: "decubitus noted on coccyx, drainage noted, culture taken..." The PA noted Physician #2 "and I personally saw/examined patient and I am acting as scribe..." The note was cosigned by Physician #2 on 11:30 a.m. on 11/2/14 when she added an addendum which noted in part: "had long discussion with patient and family today. Family upset with nursing regarding breakdown at the left calf likely due to Ted hose. Discussed that patient's skin needs more closely monitored given patient's age and comorbidities such as diabetes mellitus..."

b. No mention of skin breakdown on heel area was noted until 10/25/14. The 10/25/14 progress note was not recorded until 10/28/14 at 9:06 a.m. by the Nurse Practitioner. At this time she noted in part: "Noted a full thickness decub to L heel, floating is occurring, blister intact..."

This was less than twenty-four (24) hours prior to the patient's Acute Care Transfer on 10/31/14 at 3:18 p.m. when the nursing staff documented in part: "Patient very weak. Large skin decub on upper portion of buttocks crease. Multiple skin abrasions/wounds. Heels very sore..."

2. Review of other progress notes revealed a delay in documentation of medical progress notes, as above, in more than one (1) record. For example:

a. The 10/24/14 Progress Note for patient #1 was documented by the PA on 10/26/14.

b. The 11/15/14 and 11/16/14 Progress Notes for patient #9 were documented by the Attending Physician on 11/19/14.

These findings were reviewed and discussed with the Director of Risk Management on 12/4/14. She agreed with these findings.

The 2014 Medical Staff Rules and Regulations were provided for review. The Rules and Regulations state in part: "The attending practitioner shall be responsible for the preparation of a complete and legible record for each patient. Its content shall be pertinent...Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transfer of care, if necessary. This record shall contain...special reports, such as consultations...medical or surgical treatment...progress notes..."

3. Review of the medical record for patient #1 and review of hospital documentation of an investigation into the care of patient #1 revealed Physician #1 consulted with the patient on 10/31/14. The record contained no documentation of the medical consult by Physician #1.

This was confirmed by the Risk Manager at 3:00 p.m. on 12/1/14.

Interview was conducted with Physician #1 at 1:40 p.m. on 12/2/14. He stated he consulted with and examined patient # 1 due to a fever and fever protocol initiated the night before. He acknowledged he discovered an antibiotic had not been started the night before, as he thought, so he ordered it on 10/31/14. The Physician also acknowledged he spoke with family regarding concerns whether the patient needed to be transferred. When asked about the consult note, he stated he did not record one.

The physician noted the electronic medical record process (which was initiated in July 2014) was problematic for him. When asked if he could have recorded a hard copy consult note to be scanned into the record, he stated he was not aware of this option.

The 2014 Medical Staff Rules and Regulations were provided for review. The Rules and Regulations state in part: "The attending practitioner shall be responsible for the preparation of a complete and legible record for each patient. Its content shall be pertinent...Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transfer of care, if necessary. This record shall contain...special reports, such as consultations...medical or surgical treatment...progress notes..."

4. Review of the medical record for patient #2 revealed the patient was admitted on 11/24/14 at 3:26 p.m. Review of the History and Physical Examination revealed it was not completed until 11/26/14 at 12:29 p.m.

This was reviewed and discussed with the Director of Nursing (DON) at 11:05 a.m. on 12/3/14 and she agreed with this finding.

Review of the 2014 Medical Staff Rules and Regulations revealed in part" "A complete admission history and physical examination...shall be completed with twenty four (24) hours of admission."

Based on review of medical records, review of documents and staff interview it was determined the registered nurse (RN) failed to supervise and evaluate the nursing care for each patient for all records reviewed. The RN administered treatments and medications without orders, failed to photograph wounds per policy, failed to perform admission assessments and nutrition screening correctly, failed to perform skin care as ordered, failed to notify physician of changes in skin status, failed to establish a regular turning/repositioning schedule as ordered and failed to weigh patients as ordered for patients for ten (10) of ten (10) patients reviewed (patient #1, 2, 3, ,4 5, 6, 7, 8, 9 and 10). This creates a risk of adverse outcome for all patients.

Findings include:

1. Review of the medical record for patient #1, age 89, revealed she was admitted on 10/16/14. On 10/31/14 the patient required an acute care transfer to an outside hospital. The record reflects the patient developed fever, urinary problems and was noted to have large decub on buttocks and multiple skin abrasions/wounds, including heels.

At the time of the 10/16/14 admission nursing assessment the patient was identified as at risk for skin breakdown. On 10/18/14 the nurses documented patient complaints of heel pain. On 10/20/14 nursing staff began documenting signs of breakdown on the left heel. The record contained no documentation the physician was notified of the heel wound. Review of nursing assessments revealed nursing documentation of the patient's skin assessment was inconsistent and assessment documentation was conflicting. The record reflected nursing staff failed to institute a regular turning/repositioning schedule for the patient, instead documenting she was positioned on her back where she ultimately developed the coccyx/buttocks breakdown. The record reflects there were never any orders for wound care. A specialty mattress was not ordered until 10/28/14. Three new wounds were found on 10/29/14. Nursing noted on 10/29/14 that patient had what looked like a pressure ulcer on back of left shin due to Ted hose; another fluid filled wound at the top of the left shin and unstageable area on coccyx in addition to left alteration in skin integrity. Review of the nursing documentation revealed the nurses either did not treat the wounds or treated them without orders.

This record was reviewed and discussed with both the Director of Nursing (DON) and Director of Risk Management at 1:30 p.m. on 12/1/14. They both stated a review of the record had been completed and deficient nursing practice had been identified. They acknowledged one issue was the failure of nurses to report wounds in timely fashion and get orders for treatment. They indicated the deficient nursing practice was addressed and was corrected. They stated nursing staff was notified by memo that effective 11/13/14 nursing was not to apply dressings/products to patient for wound care without order.

2. Review of the medical record for patient #2 revealed the physician orders were written at the time of admission on 11/24/14 for wound consult for heel and coccyx and daily weights.

Review of the 11/25/14 Wound Care Consult, completed at 12:22 p.m., revealed the nurse documented: "Patient has a 5 cm x 5.5 cm soft fluid filled dark purple blister to left heel. Unable to stage area due to Suspected Deep Tissue Injury. Heel left open to air at this time. Per RN, therapy to get a Rook boot for patient to protect heel. Patient also has lymph wrap to left lower extremity. Discontinued optifoam to heel and buttock, order proposal for Dr... put in for wound cleanser, skin prep and stratasorb to left buttock daily and prn. Also, wound photo every Wednesday with measurement of left heel and left buttocks."

Interview with the Wound Consult Nurse was conducted at 12 noon on 12/3/14. She acknowledged she wasn't sure if the physician was present in the hospital at the time she performed the consult. She stated she did not notify him of the findings but instead entered the note as a proposal. She confirmed the physician did not write orders for wound care until 12/3/14, the date of the surveyor review.

Review of the 11/26/14 nursing note documented at 1339 reveals the nurse documented in part: "blood blister popped, telfa and stratasorb applied..." There was no documentation to reflect the nurse notified the physician of the change in the wound. On 11/27/14 at 11:20 p.m. the nurse documented in part: "left heel with large draining blood blister..." There was no documentation to reflect the nurse notified the physician of the change in wound.

Review of the record revealed the patient has not been weighed since 11/26/14, (8) eight days ago. The RN failed to supervise the daily weights ordered at admission for this patient.

This record was discussed and reviewed with the DON at 11:05 a.m. on 12/4/14. She agreed with these findings and stated the hospital has no process or policy for making an electronic proposal to the physicians. She stated the nurse was responsible to notify the physician either directly or by phone.

3. Review of the medical record for patient #3, admission date 11/24/14, revealed the patient had three (3) wounds on admission. Review of the medical record revealed the wounds were last photographed on 11/24/14, nine (9) days ago.

The policy, "Wound Assessment, Prevention and Documentation," last review 6/19/14, was provided for review. The policy states in part: "Regardless of time or place of origin, all wounds are to be photographed within 24 hours of discovery, weekly, and within 2 days of discharge (except when patient is unexpectedly discharged to acute care) ..."

This record was reviewed and discussed with the Director of Risk Management at 11:30 a.m. on 12/3/14. She agreed with these findings.

4. Review of the medical record for patient #4, admission date 11/19/14, revealed the patient had a wound to the coccyx at admission. Review of the medical record revealed the wound was last photographed on 11/19/14, fourteen (14) days ago.

This record was reviewed and discussed with the Risk Manager at 1:30 p.m. on 12/3/14. She agreed with the finding and acknowledged the nurse failed to follow policy for wound care.

5. Review of the medical record for patient #5, admission 11/19/14 revealed he was admitted with multiple wounds, including a healing deep venous ulcer on top on left foot. Review of the nursing admission assessment completed at 8:14 p.m. 11/19/14 revealed the nurse failed to note the wounds on the nutritional screening portion of the assessment. This resulted in an incorrect score and failure to trigger a need for nutritional screening.

The record reflected nursing failed to follow policy for photographing all the wounds. The record reflected the patient developed multiple skin tears and wounds including an excoriation on the buttocks, which were being treated by inconsistently by nursing staff without orders. On 11/28/14 an order was written to use a baby diaper to reinforce dressing to right lower extremity seeping wound. The drainage was noted by nursing as seeping onto floor. The patient continued to develop wounds which deteriorated until on 12/2/14 the patient was sent out for outside wound center consult. The patient was transferred out of the facility in an acute care transfer on 12/3/14.

Review of the record for patient #5 revealed an 11/24/14 order for daily weights. Review of the nursing documentation revealed the patient was not weighed on 11/25/14, 11/27/14, 11/29/14, 11/30/14, 12/2/14 or 12/3/14.

This record was reviewed and discussed with the DON at 1:35 p.m. on 12/3/14 and she agreed with the findings.

6. Review of the medical record for patient #6, admission 11/12/14, revealed the patient had a multiple wounds at admission. The first wound photographs were taken on 11/15/14. The next wound photographs were taken 11/22/14 then no photographs were taken until 12/1/14, nine (9) days later.

The patient had an 11/12/14 order for a dressing to the left heel, irrigate with sterile saline and dress with telfa daily. Review of the record revealed no documentation this order was performed by the nursing staff.

An additional wound order was obtained for the left heel on 11/21/14, Cleanse with soap and water, apply Bacitracin daily after cleaning wound, cover with gauze and kling. The only documentation of this wound care by nursing staff was completed on 11/27/14.

This record was reviewed and discussed with the DON at 11:30 on 12/4/14. She agreed with these findings and acknowledged the nurses failed to follow policy for wound care in addition to failing to follow orders.

7. Review of the medical record for patient #7, an admission on 11/19/14, revealed the patient had a wound to the coccyx. An admission order was written to turn patient. Review of nursing notes revealed the patient was turned at 2100 on 11/19/14. Record review revealed the patient was unable to turn self. No further documentation of turning by nursing staff was documented prior to her discharge on 11/24/14.

Patient #7 was readmitted on 11/28/14 after leaving the facility as an acute care transfer. At this time the skin was documented as intact by nursing staff but the 11/28/14 photograph taken on admission shows skin breakdown on the buttocks/coccyx area.

These records were discussed and reviewed, including the photographs, with the DON at 12 noon on 12/4/14. She agreed with these findings.

8. Review of the medical record for patient #8, admission 11/19/14, revealed she had erythema under the breast folds. The record lacked photographs or measurements of the area. The RN failed to document notifying the physician of the area. There was no further documentation of assessment or monitoring of this area.

This record was reviewed and discussed with the Wound Coordinator at 11:45 a.m. on 12/4/14. She agreed with this finding.

9. Review of medical record for patient #9, admission 11/14/14, revealed an eighty-nine (89) year old admitted with a diagnosis of Cerebral Vascular Accident (CVA). He was noted by nursing on 11/14/14 to have an excoriated buttocks. At the time of admission an order for specialty bed with mats was written. Review of nursing notes revealed no documentation to reflect the low bed with mats was implemented until 11/20/14 after the patient experienced a fall. Additionally, there was no documentation to reflect nursing reported the excoriation to the physician and nursing notes revealed the patient's buttocks were being treated without orders on 11/14/14, 11/15/14, 11/16/14, 11/17/14, 11/18/14, 11/20/14 and 11/21/14. For example on 11/16/14 the nurse noted "Calazime was applied" to the buttocks.

This record was reviewed and discussed with the DON on 12/3/14 at 4:15 p.m. and she agreed with these findings.

10. Review of the medical record for patient #10, admission 11/14/14, revealed he had an excoriated buttocks and two (2) surgical incisions and later developed an additional wound on his left shoulder on 11/16/14. Photographs were taken of the wounds at admission and the new wound on 11/16/14. There were no further photographs of wound taken prior to discharge on 11/28/14.

This record was reviewed and discussed with the Director of Risk Management at 4:00 p.m. on 12/3/14. She agreed with these findings.

Based on medical record review and interview it was determined the hospital failed to ensure the nursing staff developed and kept current nursing care plans for each patient. This failure impacted three (3) of ten (10) patients reviewed. This failure creates the potential for the nursing care of all patients to be adversely impacted.

Findings include:

1. Review of the medical record for patient #1 revealed she was admitted with a surgical wound on 10/16/14 and developed skin breakdown during her hospitalization. Review of the nursing care plan revealed the skin issues were identified and included on the plan of care by the nurse in a correct or timely fashion.

This record was reviewed and discussed with both the Director of Nursing (DON) and Risk Manager on 12/1/14 at 3:00 p.m. and they agreed with these findings.

2. Review of the medical record for patient #2, admission 11/24/14, revealed the nurse initiated a plan of care for both keeping skin intact and keeping wound free from infection. This record was reviewed with both the DON and Charge Nurse at 10:50 a.m. on 12/3/14. They both agreed this documentation was incorrect and conflicting. Both indicated nurses needed more education related to the electronic process for documentation of nursing care plans.

3. Review of the medical record for patient #3, admission 11/24/14, revealed the patient had two surgical incisions and wound to right second toe at the time of admission. Review of the Plan of Care on 12/3/14 revealed the Integumentary was not included in the plan of care.

This record was reviewed and discussed with Director of Risk Management at 11:30 a. m. on 12/3/14 and she agreed with this finding.

Based on review of documents and staff interview it was determined the director of nursing (DON) failed to provide for evaluation of the clinical activities of one (1) of one (1) non-employee personnel reviewed (RN #1). This failure creates the potential for an adverse impact on the quality of nursing care provided to all patients.

Findings include:

1. Interview with the DON at 12 noon on 12/1/14 revealed the hospital uses the services of contract nurses as needed. She confirmed that a complaint was received regarding contract registered nurse (RN) #1 on 10/30/14 regarding her competency. The DON stated the complaint was investigated and as a result on the findings the contract with RN #1 was terminated.

2. Review of the personnel/training file for RN #1 revealed no documentation of an evaluation of competency was completed by the hospital for this nurse.

3. This was reviewed and discussed with the DON at 1:00 p.m. on 12/2/14. She acknowledged that contract nurses do not receive an evaluation of clinical activities. She stated that staff nurses are provided an orientation; are assigned to work with a preceptor and must complete a skills checklist prior to working independently. The DON stated that contract nurses are told to arrive at least an hour prior to the beginning of the nursing shift in order to review and sign a packet of information and policies. She acknowledged an orientation and evaluation process for contract nurses needed to be developed.

Based on medical record review, review of documents and staff interview it was determined the hospital failed to ensure drugs and treatments are provided in accordance with the orders of the practitioner for seven (7) of ten (10) patients reviewed (patients #1, 2, 4, 5, 6, 9, 10). This failure resulted in an adverse outcome for patient #1 and patient #5 and creates a potential for the care and condition for all patients to be adversely impacted.

Findings include:

1. Review of the medical record for patient #1 revealed an acute care transfer was performed on 10/31/14. Significant nursing information was noted in part as: "Patient very weak, Large skin decub on upper portion of buttock crease. Multiple skin abrasions/wounds. Heels very sore..."

Review of a 11/2/14 Progress Note Addendum by Physician #3, revealed in part: "Had long discussion with patient and family today. Family upset with nursing regarding breakdown at left calf likely due to Ted hose. Discussed the patient's skin needs more closely monitored given patient's age and comorbidities..."

Review of nursing notes reveal nursing staff began intermittently administering treatments and dressings to patient's skin breakdown areas, such as telfa dressing to heel on 10/20/14 and sterile water then wound cleanser, Hydrogel applied to wound to buttocks and covered with stratasorb dressing on 10/31/14. The record contained no orders for wound care.

This record was reviewed and discussed with both the Director of Nursing (DON) and Director of Risk Management at 1:30 p.m. on 12/1/14. They both stated a review of the record had been completed and deficient nursing practice had been identified. They acknowledged one issue was the failure of nurses to get an order for treatment of the patient's wounds. They indicated this was corrected as nursing staff was notified by memo that effective 11/13/14 nursing was not to apply dressings/products to patient for wound care without order.

2. Review of the current medical record for patient #2 revealed nursing staff identified stage II breakdown to the left buttock and left heel blister at the time of admission on 11/24/14. Review of nursing notes revealed nursing staff regularly documented applying various barrier creams and various dressings to these areas. Review of the record revealed no order for wound care was obtained until 12/2/14, which was the day of surveyor review.

This record was reviewed and discussed with the DON at 10:50 a.m. and she agreed with these findings.

4. Review of the medical record for patient #4 revealed nursing staff identified surgical incisions and a wound at the time of admission on 11/19/14. Review of the nursing notes revealed the nursing staff were applying barrier cream to the coccyx. The chart contained no orders for wound treatment.

This record was reviewed and discussed with Director of Risk at 12:30 p.m. on 12/3/14 and she agreed with this finding.

5. Review of the current medical record for patient #5 revealed nursing staff identified an unstageable venous ulcer on the left foot, skin tears on upper and lower left arm, left and right shin skin tears and right arm skin tear at the time of admission on 11/19/14. The only wound order obtained at admission was to cleanse the ulcer on left foot with saline and apply 4 x 4 gauze dressing.

On 11/21/14 nursing documented a darkened area on left heel. On 11/22/14 nursing staff documented the patient's buttocks were excoriated. No orders were obtained to treat these areas.

On 11/25/14 the nurse documented in part: "dressing changed to bilateral upper extremity and bilateral lower extremity wounds...baby diaper applied to right lower extremity seeping wound. Drainage (serous) seeping onto floor..." On 11/25/14 an order was written for topical triple antibiotic ointment daily to left foot. On 11/28/14 an order was obtained to change dressing to bilateral lower extremities every shift and prn (as needed) due to seeping/edema and wound. Baby diaper may be used over blistered area on right lower extremity for heavy serous drainage to prevent use of adhesive to extremity.

No other wound care orders were obtained for this patient. Review of nursing notes revealed various treatments and dressings were applied throughout the hospitalization without orders. For example, on 12/2/14 the nurse documented applying wound cleanser, triple antibiotic ointment with telfa and gauze dressing to wounds on right lower leg, left shin, top of left foot and left heel.

Review of nursing notes revealed the patient's wounds worsened throughout the hospitalization. On 12/1/14 an order was written for Wound Care Consult. The ordering physician noted in part in the 12/1/14 progress note that "Followup with Wound Care Center has been ordered; however, we will try and have him seen as soon as possible secondary to the newly developing bruising/eschar on his left heel.

Record review revealed the patient went for Wound Care Consult on 12/2/14. The patient was sent out in an Acute Care Transfer on 12/3/14.

This record was discussed and reviewed with the DON at 1:35 p.m. and she agreed with these findings.

6. Review of the medical record for patient #6 revealed the nursing staff identified wounds at the time of admission on 11/12/14. The record reflects the patient had a right lower extremity skin tear, reddened area on the coccyx and reddened area on left heel. On 11/14/14 at 1:05 a.m. the nurse documented the patient had an unstagable ulceration on the coccyx and sacral area. Review of physician orders revealed an 11/21/14 order for: "Heel, soap and water, daily, apply bacitracin daily after cleaning wound. Cover with gauze and kling.

Review of the nurses notes revealed the nurse documented this order was followed one time on 11/27/14.

This record was reviewed and discussed with the Director of Risk Management at 2:00 p.m. on 12/3/14 and she agreed with this finding.

7. Review of the medical record for patient #9 revealed nursing documented the patient's coccyx was excoriated at the time of admission on 11/14/14. The nurse continued to document the coccyx was excoriated and the application of various barrier creams and medicated ointments until 11/22/14 when the area was noted as healed. The record contained no orders for the wound care.

This record was reviewed and discussed with the DON at 4:35 p.m. and she agreed with these findings.

8. Review of the medical record for patient #10 revealed nursing identified both surgical incisions and an excoriated buttocks at the time of admission on 11/14/14. On 11/16/14 the nurse identified a shoulder wound had developed. Review of nurses note for 11/9/14 at 7:00 a.m. revealed the nursing staff applied a barrier cream to the buttocks with out orders. On 11/21/14 at 1:44 a.m. and 11/22/14 at 9:09 a.m. the nurse documented application of a stratasorb dressing to the right ankle. The record contained no further documentation related to the right ankle wound and there were no wound care orders in the record.

This record was reviewed and discussed with Director of Risk Management at 4:00 p.m. on 12/3/14 and she agreed with these findings.