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Based on interview and record review the nursing staff:
1) Failed to provide wound assessments at the time of admission for 2 of 10 sampled patients reviewed.
2) Failed to provide wound treatments as ordered by the physician for 3 of 10 sampled patients reviewed.

(Patient ID#'s 1, 3, and 10)

Findings include:


Patient ID# 1

Record review of a History and Physical dated 8/5/13 revealed "History of Present Illness: The patient is a 38-year-old unfortunate gentleman who had a motor vehicle accident resulting in quadriplegia. Unfortunately, he never received a structured rehab in the past. He has continued to decline significantly and admitted for inpatient rehab program."

Record review of the nursing "Admission Database" dated 8/1/13 revealed a human diagram that listed a Stage II pressure ulcer on the sacral area. There were no measurements or assessments of the sacral pressure sore noted upon admission.

Record review of a policy titled "Wound Assessment" dated 2/2013 stated "Registered Nurse will complete a wound assessment at the time of admission.

Patient ID# 3

During an interview on 10/31/13 at 10:00 a.m. with Staff 51, RN Wound Care Nurse, she was asked to name the patients with surgical wounds or pressure ulcer wounds. She said Patient #3 had pressure ulcer wounds.

Record review of Patient #3's admission sheet and History & Physical (H&P) revealed she was admitted on 10/17/13 with diagnoses that included frequent falls, left deep vein thrombus, hypertension, history of urinary tract infections and dementia.

Record review of Patient #3's Physician's Admission Orders dated 10/17/13 under Skin Management revealed "Stage II sacral/right hip, left heel wounds. Free float heels while in bed." There were no other orders for wound treatments.

Record review of Patient #3's Daily Nursing Flow Sheet dated 10/17/13 under Nursing Notes revealed there was a dressing to the heel and lower buttock area. The human diagram area was not completed. There were no measurements or assessments of the two pressure ulcer wounds noted on any of the flow sheets. Further review of the Daily Nursing Flow Sheets from 10/18/13 to 10/20/13 revealed no documentation of measurements or assessments of the two pressure ulcer wounds. Floating the heels was documented as done on 10/19/13 and 10/20/13. There was no other documentation that the heels were floated as ordered. There was no documentation that the physician was call for orders for wound care.

Record review of Patient #3's Interdisciplinary Patient Treatment Plan of Care/Revisions dated 10/17/13 under Impaired Skin Integrity revealed a check in the section "Patient will maintain good skin integrity throughout the course of treatment at this facility. The only other statement in that section "Patient will display timely healing of wounds/incisions with no s/s (signs and symptoms) of infection" was not checked. Interventions next to the Braden Scale on the Flow Sheet were only checked on 10/18 and 10/19/13.

Record review of Patient #3's Wound Care Status Report revealed the sacral wound and left heel wound were first assessed on 10/21/13. The sacral wound measured 1.4 cm x 0.4 cm and was at a Stage III in depth. The left heel wound measured 4.4 cm x 3.8 cm and was at a Stage II.

Record review of Patient #3's Physician Order dated 10/21/13 at 3:00 p.m. revealed wound orders as follows:
1. Sacrum: cleanse daily with wound cleanser, pat dry, apply puracol to wound base, cover with 4x4.
2. Left heel: cleanse daily with wound cleanser, pat dry, cover with 4x4.

Record review of Patient #3's MAR and Nursing Notes from 9/17/13 to her discharge on 10/31/13 revealed dressing change was only noted on 9/27/13. There were no treatments sheets in the patient's clinical record.

Interview on 10/31/13 at 1:35 p.m. with Staff 50, RN Director Quality Management, she was asked if the wound should have been measured and assessed on admission. She said it should have been and there was a notebook at the nurse's station with all the forms and information needed to assess wounds. She said treatments should be listed on the MAR, on a treatment sheet or in the nurse's notes. Staff 50 looked through the patient's clinical record and was not able to show any documentation of treatments.

Closed Record Patient ID# 10

Record review of CR (Closed Record) Patient #10's admission sheet revealed she was admitted on 9/17/13 with diagnoses that included knee replacement 40 years ago, coronary artery disease, anemia, and hypertension.

Record review of a Consult Report dated 9/18/13 revealed the patient was admitted for rehabilitation status post fall with right distal femur open reduction and internal fixation. The patient had fallen on 8/12/13 and had surgery on 8/15/13.

Record review of Patient #10's Physician Admission Orders dated 9/17/13 revealed an order to shower the patient daily with Hibiclens. Hibiclens is an antiseptic/antimicrobial skin cleanser. A box was checked under Skin Management to provide routine dressing change daily and as needed until there was no drainage.

Record review of the daily Nursing Notes from 9/17/13 to 9/22/13 revealed either the wound dressing was dry and intact or nothing was noted about the wound. On 9/23/13 at 3:45 p.m. the wound dressing was changed and serous drainage was noted. At 12 midnight wound care was given with serous drainage noted. Xeroform and 4x4 gauze were applied to the wound. Xeroform is petroleum jelly and bismuth tribromophenate used as an external antiseptic.

Record review of Patient #10's Physician's Orders from 9/17/13 to 9/23/13 revealed no orders for treatments for the knee wound.

Record review of Patient #10's Medication Administration Record (MAR) and Nurses' Notes revealed no documentation that the resident was bathed with Hibiclens on 9/19, 9/23, 9/25, and 9/26/13.

Further record review of Patient #10's Nursing Notes dated 9/25/13 revealed a full dressing change was done on the right knee and the dressing was saturated with blood and puss.

Record review of Patient #10's Physician's Orders dated 9/25/13 revealed an order for ? strength Dakin's solution wet to dry dressing twice a day. Dakin's solution is a type of hypochlorite solution made from bleach used to prevent and treat skin and tissue infections. On 9/28/13 there was an order to apply a Wound Vacuum to the right knee and change every 2 days.

Record review of the Patient's MAR and Nursing Notes revealed no documentation that the Dakin's dressing was done on 9/26/13 in the morning or 9/27/13 in the evening.

Record review of the wound pictures and Wound Care Status Report dated 9/17/13 revealed a 30 cm surgical wound on the right knee that had non-blanchable erythema on intact skin. On 9/25/13 two pictures of the right knee showed multiple open areas that had yellow slough type exudate. A third picture was taken after the wound had been debrided at a physician's office. There were no measurements noted on any of the pictures or on a Wound Care Status Report. On 9/30/13 there was a picture of the surgical wound which was labeled as a dehiscence. Three wounds were noted with measurements as follows:
1. 3.7 cm x 2 cm x 1.8 cm
2. 1.6 cm x 1.7 cm x 1.7 cm
3. 2.2 cm x 1.5 cm x 1.2 cm
There were no descriptions of the wound bed, skin edges, exudate, or undermining.

Interview on 11/1/13 at 2:35 p.m. with Staff 50, RN Director of Quality Management, she was asked what the routine dressing change was for Patient #10. She said if the surgical wound was closed, the area would be cleaned during her showers and then left open to air. Staff 50 looked through Patient #3's closed record. She was unable to find documentation of wound assessments and measurement before 9/27/13 or documentation of Hibiclens and Dakin treatments on the dates in question.

Interview on 11/1/13 at 10:30 a.m. with LVN Staff 56, she was asked what was done for a patient who admitted to the facility with a wound. She said they had a wound care book. She said they would measure the wound, get a picture of the wound, document on the assessment sheet and then call the physician for appropriate orders. She said the admitting nurse would initiate the assessment/treatment and then inform the Wound Care Nurse.

Interview on 11/1/13 at 12:10 p.m. with RN Staff 57, she was asked who was responsible for assessing wounds. She said if the wound was a Stage I, they would use protective lotion and monitor. If it was a Stage II or greater, then they would have to get a physician ' s order to treat. She said the admitting RN would do the assessments and they would then notify the Wound Care Nurse to let her know she needed to do weekly measurements.

Record review of the facility's Policy and Procedure for Wound Assessment dated 2/2013 under Procedure revealed the following: "RN will complete a wound assessment at the time of admission. An initial assessment of major wounds by the wound Care Coordinator/designee will be provided within 48 hours of the admission date ..."

Record review of the facility's Policy and Procedure for Initial Wound Treatment dated 2/2012 under Policy revealed the initial wound treatment provided options for the staff nurse to initiate wound care on newly admitted patients and those developing new wounds if the Wound Care coordinator was unavailable for immediate assessment of the patient's wounds. Under Procedure the wound was to be cleaned with normal saline, photographed and measured per photographing wound guidelines. Orders were to be obtained for the appropriate topical dressing following wound criteria. There were several dressing protocols listed on the page.

Based on observation, interview and record review the nursing staff failed to develop a comprehensive nursing care plan for 6 of 10 sampled patients that included interventions. (Patient ID#'s 1, 2, 3, 4, 5, 10)

Findings include:

PATIENT ID# 1
Record review of the medical record for patient ID# 1 revealed he was admitted on 8/1/13 and discharged on 10/16/13.

The hospital failed to develop a care plan for patient ID# 1 that included pressure ulcer prevention, urinary incontinence, bowel incontinence, and behavioral issues related to refusal of care / treatments.

A history and physical dated 8/5/13 stated Admitting Diagnoses:
1) Traumatic C5 quadriplegia
2) Neurogenic bladder
3) Neurogenic bowel

"History of Present Illness: The patient is a 38-year-old unfortunate gentleman who had a motor vehicle accident resulting in quadriplegia. Unfortunately, he never received a structured rehab in the past. He has continued to decline significantly and admitted for inpatient rehab program."

Record review of the nursing admission assessment for patient ID# 1 dated 8/1/13 revealed the patient had one stage II sacral pressure ulcer upon admission. No other skin problems were noted.

Review of the nursing notes for patient ID# 1 revealed the patient developed six pressure ulcers while a patient in this hospital. (left sacral stage II; right lateral calve stage III; left lateral calve stage III; right elbow stage II; left elbow stage II; right heel and left heel)

Record review of "Interdisciplinary Patient Treatment Plan of Care / Revisions" initially dated 8/1/13 revealed the patient was not care planned for Bowel and Bladder management. The problem of "Impaired Skin Integrity" was identified with the goal stating "Patient will maintain good skin integrity throughout the course of the treatment at this facility." The Plan of Care failed to identify preventative interventions to prevent skin impairment. The problem of "Positioning / Pressure Reduction" was identified and the goal stated "Patient will receive appropriate cushions / positioning devices to maintain good posture, alignment and skin integrity while in bed and up in chair." The only intervention listed was "Pressure mapping."

The Plan did not list what type of cushions or positioning devices were used to prevent further pressure ulcers.

Interview 10/31/13 at 9:50 a.m. with the Wound Care Nurse, ID# 51 revealed patient ID# 1 sat in his electric wheelchair up to 8 to 10 hours per day per his choice. The patient declined to get out of the wheelchair when requested by staff. The patient also refused treatment / care at times. This behavior was not addressed in the patient's Care Plan.

Patient ID #3
Observation on 10/31/13 at 9:50 a.m. revealed Patient #3 was a small, thin frail female who was unable to give current information about herself. There was a notice on the wall above her bed that informed staff that the resident was on pureed diet with nectar thick liquids and at risk for aspiration. The resident had an indwelling urinary catheter.

Record review of Patient #3's admission sheet and History & Physical (H&P) revealed she was admitted on 10/17/13 with diagnoses that included frequent falls, left deep vein thrombus, hypertension, history of urinary tract infections and dementia.

Record review of Patient #3's Physician's Admission Orders dated 10/17/13 under Skin Management revealed "Stage II sacral/right hip, left heel wounds. Free float heels while in bed."

Record review of Patient #3's Nursing Notes dated 10/17/13 revealed she was transferred from a local hospital where she was diagnosed with urosepsis, debility, and hypovolemic shock. Urosepsis is poisoning from the absorption and decomposition of urinary substances in the tissues. Hypovolemic shock is when there is an abnormally decreased volume of circulating fluid in the body.

Record review of the resident's Interdisciplinary Patient Treatment Plan of Care/Revisions dated 10/17/13 revealed nursing documented the following areas that they were to address:
Safety Awareness/Alteration in Safety - 2 of 2 goal boxes checked
Potential for Injury Related to Falls - 1 0f 1 goal box checked
Pain Management - 1 of 1 goal box checked
Positioning/Pressure Reduction - 1 of 1 goal box checked
Impaired Skin Integrity - 1 of 2 goal boxes checked.

Under Impaired Skin Integrity, the checked box was that the patient would maintain good skin integrity throughout the course of treatment. (The resident was admitted with two pressure ulcers) The other box was that the patient would display timely healing of wounds/incisions with no signs or symptoms of infection. That box was not checked. The problem of nutrition was not checked. There were no interventions for the problems noted.

Record review of Resident #3's Daily Nursing Flow Sheets revealed Interventions next to the Pressure Ulcer Risk scale. These interventions were only checked on 10/18 and 10/19/13.

Patient ID #2

Record review of Patient #2's History and Physical revealed he was admitted on 10/23/13 with diagnoses that included coronary artery disease, congestive heart failure, hypertension, hypothyroidism, history of gastrointestinal (GI) bleeding, history of bilateral pulmonary embolism. The resident had a reversal of his colostomy prior to admission to the hospital.

Record review of Patient #2's Nursing Notes dated 10/25/13 revealed a wound vacuum was applied.

Record review of Patient #2's Interdisciplinary Patient Treatment Plan of Care/Revisions dated 10/23/13 Nursing documented the following areas that they were to address:
Potential for injury Related to Falls, Impaired skin Integrity, and Pain Management.

The care plan was the same as for Patient #3 with checks to be put by goals. There were no interventions.

Patient ID #4

Record review of Patient #4's History and Physical revealed she was admitted on 10/20/13 with diagnoses that included small bowel obstruction resection on 9/29/13.

Record review of Patient #4's Nursing Notes dated 10/20/13 revealed her diagnoses included cerebral vascular accident with left sided weakness, drooping face, stage II pressure ulcer to right buttock, indwelling urinary catheter, 3 plus left upper extremity edema, and contracted left hand.

Record review of the patient's Interdisciplinary Patient Treatment Plan of Care/Revisions dated 10/20/13 revealed no Nursing areas were documented.

Patient ID #5

Observation on 10/31/13 at 10:41 a.m. revealed Patient #5 was in bed. Staff were putting on gowns before entering the room. A sign at the door noted the resident was on Contact Isolation. He had an indwelling urinary catheter to bedside drainage. A nurse was irrigating the resident's gastric tube.

Record review of Patient #5's History and Physical dated 10/16/13 revealed the resident was admitted on 10/16/13 with diagnoses that included traumatic brain injury after skull fracture, flap surgery for sacral decubitus, and history acute respiratory failure with tracheostomy.

Record review of Patient #5's Physician ' s orders revealed an order for contact isolation for MRSA (Methicillin Resistant Staph Aureus) and oxygen per nasal cannula.

Record review of Patient #5's Interdisciplinary Patient Treatment Plan of Care/Revisions dated 10/16/13 revealed nursing was involved in the following areas:
Community Re-entry, Work/Leisure, Case Management-Discharge planning and Case Management.

There was nothing addressing the patient's contact isolation, prior decubitus with corrective flap surgery, or use of oxygen. There were no interventions.

Closed Record (CR) Patient ID# 10

Record review of CR (Closed Record) Patient #10's admission sheet revealed she was admitted on 9/17/13 with diagnoses that included knee replacement 40 years ago, coronary artery disease, anemia, rheumatoid arthritis with upper and lower extremity deformities, and hypertension.

Record review of a Consult Report dated 9/18/13 revealed the resident was admitted for rehabilitation status post fall with right distal femur open reduction and internal fixation. The resident had fallen on 8/12/13 and had surgery on 8/15/13.

Record review of Patient #10's Admission/New Wound Photographic Documentation sheet dated 9/30/13 revealed the resident's wound had a dehiscence.

Record review of Patient #10's Interdisciplinary Patient Treatment Plan of Care/Revisions dated 9/17/13 revealed nursing was involved in the following areas:
Safety Awareness/Alteration in Safety, Potential for injury related to Falls, Impaired skin Integrity, Pain Management, Positioning/Pressure Reduction, and Infection Control. There were no interventions for these areas. There was no revision of the care plan to address the right knee dehiscence.

Interview on 10/31/13 at 1:35 p.m. with RN Staff 50, Director Quality Management, when she was asked if she felt the current care plan addressed problems, set goals and provided interventions, said she and RN Staff 52, Chief Clinical Officer, were aware that it did not address nursing issues. She said it was a corporate form and they were working to get a different type of care plan.

Interview on 11/1/13 at 10:30 a.m. with LVN Staff 56, she said she had worked at the facility for one year. She said the admitting nurse was responsible for initiating the care plan. She said as things came up, then all the nurses were responsible for updating the care plan. She was asked if she felt the care plan was individualized for each resident and if it covered all the areas that nursing would be responsible for. She said she did not feel it covered all the areas that should be care planned.

Interview on 11/1/13 at 1:10 p.m. with RN Staff 52, Chief Clinical Officer, he was asked who was responsible for assessing residents for the care plan and filling out the care plan. He said the RN admitting nurse started the care plan and then in an Interdisciplinary team meeting finalized the plan of care.

Record review of the facility's Assessment/Reassessment- Interdisciplinary Patient Care Delivery dated 8/2013 revealed the Purpose was as follows:
To assure care was provided to each patient based on an assessment of the patient ' s relevant physical, psychological and social needs.
To establish a comprehensive information base for decision making about each patient ' s care,
To define initial assessment time frames
To determine the appropriate care, treatment, and services to meet the patient ' s needs during hospitalization.

The Policy was as follows:
" 1. All patients at (hospital) will have an initial assessment and appropriate follow up assessments based upon patient specific identified needs including physical, psychological, and social-cultural status.
2. The goal of the Assessment/Reassessment process is to provide an interdisciplinary approach for assessment(s) (and ongoing reassessment(s)) of individual patient care needs and for planning and implementing patient specific care.
3. Care and/or treatment provided by all health care professionals will be based on each patient ' s specific needs ....
4. Assessments and data collection performed by licensed health care professionals will include and address: ....
Data analysis to develop a plan of care to meet the patient ' s care or treatment needs ....

Nursing Department ....
3. The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems and patient specific needs ...."