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Based on interviews and documentation review the Long Term Acute Care (LTAC) Hospital failed to ensure that: the Patient ' s reddened coccyx was documented upon admission; skin assessment documentation was accurate, and turning and repositioning was consistently documented.

Findings included:

The medical record documentation indicated that the Patient, was experiencing worsening shortness of breath on exertion and chest discomfort. The Patient was admitted to Hospital #1 on 3/4/10 the Patient underwent a coronary artery bypass graft (surgical procedure to replace the 3 blocked coronary vessels) and an aortic valve replacement (replacement of the aortic valve in the heart with a functioning artificial valve; complications can occur depending on the patient's overall health prior to the surgery and the presence of risk factors such as diabetes; possible complications include atrial fibrillation, infections, pneumonia, and/or fluid build-up in the lungs). Post-operatively the Patient suffered from multiple complications including: respiratory failure requiring intubation (ETT; insertion of a tube through the mouth down the throat to the trachea to provide a patent airway; increases risk of respiratory infection) and mechanical ventilation (machine to provide or assist the patient with breathing); tracheobronchitis/pneumonia; congestive heart failure (CHF; accumulation of fluid around the heart); electrolyte imbalances requiring intravenous therapies; a urinary tract infection (possibly related to the use of a Foley catheter); atrial fibrillation (a rapid weak heart rate; increases risk of blood clot development); deep vein thrombosis (blood clot) of the left axilla; delirium (acute onset of confusion); acute kidney injury; anemia, and mild coccygeal redness.

The discharge documentation from Hospital #1, sent to the LTAC Hospital with the Patient on 4/5/10, indicated that the Patient had a reddened coccyx.

The LTAC Hospital medical record documentation, dated 4/5/10, indicated that upon admission an admission nursing assessment was completed. The Patient's skin was pale, warm, dry, smooth, well hydrated and intact. There was no documentation regarding the reddened coccyx identified at Hospital #1.

The medical record documentation, dated 4/6/10, indicated that on 4/6/10 the Patient was evaluated by the Physiatrist, Physical Therapy, Occupational Therapy, and the dietician. The Patient was identified as having a Stage II pressure ulcer (partial thickness loss; shallow with a red base; such as with an open blister) at the gluteal crease measuring 2.5 centimeters (cm) by 0.5cm.

The Wound Nurse was interviewed intermittently throughout the survey. The Wound Nurse said that there was an order in the electronic medical record to turn and reposition the Patient every 2 hours.

Certified Nurse Aide (CNA) #1 was interviewed on 6/30/10 at 7:35 A.M.; CNA #2 was interviewed on 6/30/10 at 2:15 P.M.; CNA #3 was interviewed on 6/30/10 at 2:30 P.M.; CNA #4 was interviewed on 6/30/10 at 2:30 P.M.; CNA #5 was interviewed on 6/30/10 at 2:50 P.M.; CNA #6 was interviewed on 7/1/10 at 5:45 A.M., and CNA #7 was interviewed on 7/1/10 at 5:50 A.M. CNA #1 said the Patient was turned and repositioned; CNA #2 and CNA #3 said the Patient was capable of turning self but did not unless initiated by staff; CNA #4 said the Patient was turned and repositioned however; the Patient preferred to be on the back and would reposition to the back even though put on the side, and CNA #5, CNA #6, and CNA #7 did not remember the Patient.

The medical record documentation, dated 4/7/10 to 5/11/10, indicated the Patient was evaluated by physical therapy and was determined to require minimum assistance of 1 and verbal cues for repositioning. Documentation regarding turning and repositioning was inconsistent regarding both frequency and the type of assistance provided.

The medical record documentation, dated 4/6/10 to 5/14/10, indicated that the Patient's skin was assessed by nursing each day however; documentation as to whether the skin was intact or not intact was inconsistent.

Nurse #1 was interviewed on 6/30/10 at 8:00 A.M.; Nurse #2 was interviewed on 6/30/10 at 1:50 P.M.; Nurse #3 was interviewed on 6/30/10 at 3:00 P.M.; Nurse #4 was interviewed on 7/1/10 at 5:35 A.M.; Nurse #5 was interviewed on 7/1/10 at 5:40 A.M.; Nurse #6 was interviewed on 7/1/10 at 11:20 A.M., and Nurse #7 was interviewed on 7/6/10 at 11:30 A.M. Nurse #1, Nurse #2, Nurse #3, Nurse #4, Nurse #5, and Nurse #7 said they either could not remember the Patient or specifics regarding the Patient's skin condition. Nurse #6 said documenting skin not intact meant the Patient had openings such as a tracheostomy or a GT. Nurse #6 said if a pressure sore was identified then the location and a description of the area would have been documented.

The Unit Manager was interviewed intermittently throughout the survey. The Unit Manager said the nurses should only be documenting the skin was not intact when there was a wound present and not when there was an opening such as a tracheostomy or GT. The Unit Manager said if there was a wound present the nurse was supposed to document the location, size, and description of the wound. The Unit Manager said the CNA's should be documenting the frequency of turning and repositioning.

Based on interviews and documentation review, the Long Term Acute Care (LTAC) Hospital failed to ensure that pressure ulcer data entered into the tracking report was accurate for one of one patient (the Patient).

Findings included:

The discharge documentation from Hospital #1, sent to the LTAC Hospital with the Patient on 4/5/10, indicated that the Patient had a reddened coccyx.

The LTAC Hospital medical record documentation, dated 4/5/10, indicated that upon admission an admission nursing assessment was completed. The Patient's skin was pale, warm, dry, smooth, well hydrated and intact. There was no specific documentation regarding the condition of the coccyx.

The medical record documentation, dated 4/6/10, indicated that on 4/6/10 the Patient was evaluated by the Physiatrist, Physical Therapy, Occupational Therapy, and the dietician. The Patient was identified as having a Stage II pressure ulcer (partial thickness loss; shallow with a red base; such as with an open blister) at the gluteal crease measuring 2.5 centimeters (cm) by 0.5cm.

The Wound Nurse was interviewed intermittently throughout the survey. The Wound Nurse reported assessing all new admissions and first assessed the Patient on 4/6/10.

Review of the Units ' April, 2010 Pressure Ulcer Tracking Report indicated that the Patient was entered as having a Stage II coccygeal pressure ulcer present on admission, 4/5/10.