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Based on record review, and interview the facility failed to ensure that registered nurses failed to assess and elevate patients for potential skin breakdown in three out of seven patients admitted through the emergency department (Patient, ID#1,2, 8).

Findings Include:

Record review of three patients (ID#1,2, 8) who were admitted on 01/22/21 and 01/30/2021 from the emergency department. The documentation revealed the patient had no skin issues and skin was Intact. The nursing staff did not implement the facility's Skin Risk Nursing Protocol for patients at risk for skin breakdown.

Record review of the emergency department (ED) noted dated 01/23/2021 revealed patient (ID#1) an 83 year- old- female, who was admitted for respiratory distress and it was documented that her skin was intact. A wound care assessment was triggered on 01/28/2021 for this patient who had bilateral hips and sacral area open with scar tissue, and bilateral feet were noted to have with multiple diffuse areas of deep tissue injury and pressure injury.

Record review of the ED noted dated 01/22/2020 revealed patient (ID# 2) an 83-year-old male, who was admitted with acute hypoxic respiratory failure secondary to pneumonia. The documentation revealed the patient had no skin issues and skin was Intact. The skin risk assessment was completed 01/24/2021, posterior sacrum, stage III. The first wound order was noted on 01/26/21 @1513 for silver alginate dressing to a open wound.

Record review of the ED noted dated 01/30/2021 revealed patient (ID# 8) an 58-year-old male, who was admitted from the ED for aspiration pneumonia, anoxic encephalopathy. The documentation also revealed the patients was intact skin and no other skin integrity issues were found. Four days later, 02/03/2021 the wound care nurse was consulted and documented the wound.

Interview with nurse (ID# 57) on 02/12/2021 at 1145, who stated "we chart by exception, and it is easier to chart what is pertinent to the patient, especially in the ED. The ED staff documents the chief complaint, that is why they are not addressing the patient's skin at admission. The system stages the wound for the nursing the staff. If it is not documented, it is not done."

Interview with wound care nurse (ID# 65) at 02/12/2021 at 1040 who stated, "we go by the physicians note and make recommendations about the wound. We are just asking staff to write what they see".

Record review of the facility policy "Clinical Practice Guidelines for Skin Alterations" dated 01/2020 stated the Purpose "To ensure all patients will be properly screened for the presence of skin alterations (also known as wounds, ulcers, injuries) and for risk of, or presence of pressure injuries.
The Adult Skin Risk Nursing Protocol, stated should the adult patient be at risk for any of the risk factors within the Adult Skin Risk Assessment, the Adult skin risk Nursing Protocol is to be implemented.