HospitalInspections.org

Based on review of documentation and in-person interviews with staff # 3 and 9, the facility failed to ensure that patient # 1 receive safe care; patient # 1 develop skin wounds. during her hospital stay. at the facility.
Findings were:
Review of Bradenton Risk Assessment of patient # 1 on admission 11/28/12 stated"no skin breakdown."
Review of Pressure Ulcer Prevention and Management, Policy # NA-0284 stated "A. The Bradenton Risk Assessment Toll is used to assess and document patient at risk for skin breakdown. the Braden Risk Assessment Tool will be done on all inpatients to measure functional capabilities of the patient that contribute to higher of lower risk for pressure tolerance."

Review of 24 hour Nurses Notes 11/29/12 stated,"skin intact, temp/moisture warm/dry, Turgor normal, integument intact"
Review of 24 hour Nurses Notes 12/7/12 7a-7p, 12/9/12 7a-7p No dermal assessment or wound care was documented.

Review of Consult 12/07/12 per staff # 11 stated, "Extremities with no edema. There is a diaper in place. There is no Foley catheter. On both the inguinal region and bilateral buttocks there is rash that is erythematous, slight increase in temperature. There are multiple areas of open skin that shows some ulceration that are partial thickness consistent with candidiasis with some satellite lesions that are present around the inguinal region."
Review of 24 hour Nurses Notes 12/7/12 7a-7p, 12/9/12 7a-7p No dermal assessment or wound care was documented

Review of Wound Care Progress Note upon discharge 12/10/12 per staff # 11 stated,"Skin wound #1 in the buttocks, inguinal and perineum area per nursing staff, erythema has improved and is contracting. This is an erythematous rash with satellite lesion"

In an in-person interview conducted with staff # 3 and # 9 on 2/26/13 at 9:15 a.m. at the facility; it was confirmed that the patient # 1 develop skin wounds durning her hospital stay.
Review of Wound Care Progress Note upon discharge 12/10/12 per staff # 11 stated,"Skin wound #1 in the buttocks, inguinal and perineum area per nursing staff, erythema has improved and is contracting. This is an erythematous rash with satellite lesion"

In an in-person interview conducted with staff # 3 and # 9 on 2/26/13 at 9:15 a.m. at the facility; it was confirmed that the patient # 1 develop skin wounds durning her hospital stay.