HospitalInspections.org

Based on record review and staff interview, the hospital failed to ensure nursing supervised the care for one of ten patients reviewed (Patient #3). This deficient practice had the potential to affect any patient with skin integrity risk factors. The facility identified 52 patients with hospital acquired pressure areas. The census of the facility was 546 patients.

Findings include:

Review of the medical record for Patient #3 revealed an admission date of 10/25/2020 for a fall with a right femur fracture, and a history of pancreatic cancer, stroke, and osteoporosis. Patient #3 had been assessed for skin risk with a Braden scale score of 13, moderate risk. Review of nursing notes revealed on 11/03/2020 at 12:00 AM an area of red skin was observed on the patient's sacrum and a dressing was applied after cleansing the area. Review of a wound care assessment consult completed on 11/03/2020 revealed an assessment of a 2.0 centimeter (cm) by 1.0 cm purple area, stage one on the coccyx, unknown causation, with instruction to apply Triad paste daily (wound/skin protective barrier), assess the skin every shift and reposition patient every two hours and as needed.

Review of the nursing flow records for Patient #3's skin assessment revealed there was no assessment with measurement completed since the area was initially identified on 11/03/2020. Patient #3 was discharged from the facility on 11/14/2020.

Interview with Staff E on 11/17/2020 at 10:52 AM confirmed there was no documentation a wound measurement had occurred since 11/03/2020.