HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:

1. Monitoring of ordered precautions and alterations in skin for three (Patients #5, #6, and #8) of eight patients.

2. Coordination of care for one (Patient #6) of eight patients.

This failed practice has the likelihood to place patients at risk of injury, delayed recognition of medical condition and delayed receipt of medical treatment.

Review of a policy titled "Fall Risk Assessment" read in part, "If the fall assessment score is greater than or equal to 25, initiation of the fall precautions treatment plan is indicated ...can be initiated at any time during hospitalization that a change in condition and/or risk factors occurs."

Review of a policy titled "Skin Assessment" read in part, "All patients shall receive a daily skin reassessment, which shall be documented on the Daily Nurse Reassessment Progress Note. Patients with significant skin conditions, including those at risk of skin breakdown shall [sic] be receive comprehensively detailed skin reassessments which shall be documented by a nurse on a Skin Reassessment form until the bruising or wound has resolved ...Complete the Skin Assessment section of the Daily Nursing Reassessment Progress Note, daily for all new and previously identified bruises and wounds, indicating skin conditions on the body diagram ...For patients with new ...skin conditions ...complete a Skin Reassessment form, documenting all abnormalities on the body chart diagram. Examine and reassess the patient daily until the bruising or wound has resolved. Carefully note changes in color, shape, and size, and other details ...Risk Manager or Designee: For bruises and wounds that develop during a patients stay, which are reported on an incident report form, take photographs of all affected areas of the patient's body."

Fall Precautions

Patient #5

Review of a document titled "Admission Order" dated 04/09/21 at 7:20 PM showed an order for fall precautions.

Review of a document titled "Morse Falls Assessment" showed a score of 55 on 04/23/21 and 04/30/21 for Patient #5 and documented that a score of 45 or greater was a high risk level.

Review of a document titled "Nursing Reassessment" dated 04/26/21 showed documentation of no fall precautions for both the day and night shifts, signed by two different registered nurses at 10:44 AM and 9:45 PM, respectively. Review of a document titled "Progress Notes" dated 04/26/21 showed the patient experienced a fall on 04/26/21 at approximately 2:50 AM.

On 06/09/21 at 2:02 PM, Staff E reviewed the medical record for Patient #5 and stated the following:

1. The admission order for fall precautions had not been discontinued.

2. The patient should have been on fall precautions on 04/26/21.

3. Nurses were to be aware of precautions to keep patients safe.


Skin Assessment

Patient #5 - Hematoma

Review of an internal document showed on 04/26/21 at approximately 2:50 AM, the patient experienced a fall, hitting the right side of the back of his or her head, resulting in a hematoma. The internal document showed no size or other characteristics of the hematoma and no photographs were provided to the surveyors.

Review of documents titled "Nursing Reassessment" dated 04/26/21 and 04/27/21 for both the day and night shifts, each signed by two different registered nurses, showed no description of the skin assessment and showed no documentation of a hematoma to the right side of the back of the patient's head.

Review of a document titled "Daily Progress Note-Medical" dated 04/26/21 at 11:35 AM showed no documentation of a hematoma to the right side of the back of the head and showed no documentation of physical examination of skin.


Patient #5 - Skin Tear

Review of an internal document showed on 05/06/21 at approximately 3:10 PM, staff cleaned and placed a dressing to the patient's left forearm skin tear following a physical restraint. The internal document showed no size or other characteristics of the skin tear and no photographs were provided to the surveyors.

Review of documents titled "Nursing Reassessment" dated 05/07/21 and 05/08/21 for both the day and night shifts, each signed by two different registered nurses, showed no documentation of a left forearm skin tear or status of a dressing.

Review of a document titled "Daily Progress Note - Medical" dated 05/10/21 (time illegible) showed no documentation of a left forearm skin tear and showed no documentation of physical examination of skin.

On 06/09/21 at approximately 2:37 PM, Staff E reviewed the medical record for Patient #5 and stated the following:

1. Nursing was expected to monitor wounds and complete a wound sheet for the hematoma and skin tear but did not.

2. The risk of not monitoring the hematoma was not knowing if it was increasing in size.

3. The risk of not monitoring the skin tear was infection or poor healing.

4. Medical saw the patient on 04/26/21 and 05/10/21 did not document the hematoma or skin tear.


Patient #6 - Old Brown Chest Bruise

Review of a document titled "Daily Progress Note - Medical" dated 04/20/21 at 1:15 PM by the NP showed no documentation of bruising to chest wall.

Review of the medical record for Patient #6 found no Skin Reassessment form for 04/22/21 and did find a document titled "Nursing Reassessment" dated 04/22/21 at 5:00 PM which indicated a chest bruise on the body diagram and read in part, ' ...NP notified of old brown bruising to chest wall. [NP] stated "[NP] seen [the patient] 2 days ago and was there."'


Patient #6 - Red Eye

Review of a document titled "Summary Sheet" showed the patient admitted to Rolling Hills Hospital on 04/15/21.

Review of a document titled "Nursing Assessment" dated 04/15/21 at 9:00 PM showed no markings on the body diagram and read "No Significant Findings ...Skin: No history of problems."

Review of documents titled "Nursing Reassessment" and "Progress Notes" dated 04/15/21 through 04/21/21 showed no documentation of bruising to chest wall or redness to eyes.

Review of the medical record for Patient #6 found a document titled "Progress Notes" dated 04/23/21 from 2:50 PM to 4:40 PM which read in part, "(R) eye noted red in [sic] outter corner ...(R) Eye [with increased] redness to (R) [sic] outter corner," and found no Skin Reassessment form with the skin alteration indicated.

On 06/09/21 at 2:37 PM, Staff E stated, nurses were expected to create a wound sheet for skin alterations.

On 06/10/21 from 1:37 PM to 2:50 PM, Staff E reviewed the medical record for Patient #6 and stated the following:

1. The patient had no bruises at admission.

2. They were not certain how the bruise or eye redness was caused.

3. Staff were "absolutely" supposed to take pictures upon finding skin issues. "It's a CYA thing." Staff were trained on this in the past year. There was no policy on taking pictures. Staff should have taken pictures of the bruising for Patient #6 but did not.


Coordination

Patient #6

Review of a document titled "Progress Notes" dated 04/23/21 at 6:00 AM, written by a behavioral health assistant, read in part, "Pt did not sleep for almost 24 hours, pt is shaky, has cold in [his/her] lungs and very unstable," and showed no documentation of nurse or physician notification.

Review of a document titled "Discharge Summary" dated 05/14/21 at 8:00 AM read in part, "On 04/23/21, the patient at [4:55 PM] [sic] the patient is being transferred to Mercy Ada ER nonemergent for a higher level of care and multiple contusions."

On 06/10/21 from 1:37 PM to 2:50 PM, Staff E reviewed the medical record for Patient #6 and stated the following:

1. He or she did not see where the behavioral health assistant notified the nurse of the patient's presentation on 04/23/21 at 6:00 AM. Notification should have occurred so the patient could have been seen by a medical professional.



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Skin Assessment

Patient #8

During a review of the clinical record, the surveyor noted the following:

1. On a form titled "Nursing Reassessment" dated 04/14/21, nursing staff documented "Small cut to ring finger (right) hand" in the skin assessment. There was no Skin Reassessment form or picture found in the record.

2. On the same titled form dated 04/15/21, nursing staff did not document any findings in the skin assessment.

3. On the same titled form dated 04/16/21, nursing staff did not document any findings in the skin assessment.

4. On the same titled form dated 04/17/21, nursing staff documented "red (with) temp" with a line drawn to indicate the right arm on a diagram, also documented "red patched" and circled the chest, left arm, and both lower legs on the diagram. There was no Skin Reassessment form or picture found in the record.

5. On the same titled form dated 04/18/21, nursing staff did not document any findings in the skin assessment.

6. On the same titled form dated 04/19/21, nursing staff documented "multiple contusions" and circled both arms and both lower legs on the diagram. There was no Skin Reassessment form or picture found in the record.

7. On the same titled form dated 04/20/21, nursing staff did not document any findings in the skin assessment.

The patient was transferred to an acute care setting on 04/20/21 for cellulitis of the right forearm.


During an interview on 06/10/21, Staff H reported nursing staff conducts a full body skin assessment once every 24 hours, including when the patient has a known wound. The surveyor asked what actions should be taken upon discovery of a new skin concern, Staff H stated the nurse should document a description in a narrative note, inform the nurse for the next shift in report of the change in condition, and take pictures. The surveyor asked if pictures were taken of all wounds, Staff H stated nursing staff were told by the Director of Nursing to take pictures but "it isn't done every time."