HospitalInspections.org

Based on policy review, record review, and interview, the facility failed to ensure the nursing staff conducted patient assessments for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. The facility's "Wound Care" policy dated 5/2021 revealed, "...To provide a consistent process for accurate and complete documentation of wound assessments and treatments...New skin tears, bruises, abrasions and lacerations and any other injury/ulcer must be monitored and documented in the Nurses Notes every shift for the first 72 hours..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 8/10/2022 with diagnoses which included Alzheimer's disease with late onset, and Hypertension.

The admission "History and Physical" dated 8/11/2022, revealed Patient #1 did not have any open wounds.

The "Skin Assessment" dated 8/14/2022 at 1:56 PM, revealed there were no skin integrity issues identified for Patient #1.

Patient #1 was discharged home on 8/25/2022 at 4:00 PM.

There was no documentation in the medical record of an injury to Patient #1.

3. In an interview in the office on 9/14/2022 at 9:20 AM, the Director of Nursing (DON) revealed he noted in Patient #1's chart, a skin tear the patient received while showering, was not documented. The DON revealed a band aid was initially placed on the wound, as it was "more superficial", but the patient pulled it off.