HospitalInspections.org

Based on policy review, medical record review, photos and interviews, the hospital failed to ensure nursing staff accurately documented the skin condition to include bruising in the medical record for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy, "NO ULCERS BUNDLE and Skin Care Policy" revealed, "A Braden Scale assessment is performed on admission and daily...Assess and document integrity of skin...daily and PRN [as needed]...Identify level of risk, assess skin integrity, develop and implement plan of care to maintain/improve skin...The Braden Scale is a tool to systematically assess for risk for potential development of pressure ulcers and skin breakdown...All skin assessments...are documented in the medical record...Inspect skin from head to toe within 6 hours pf admission, every day and upon transfer to a unit...Daily inspection thereafter or upon transfer between units is to be performed by RN/LPN [Licensed Practical Nurse]..."

2. Medical record review for Patient #1 revealed a 80 year old male presented to the emergency department (ED) via Emergency Medical Services (EMS) on 2/17/2021 with complaints of multiple fall episodes over the previous days, that included a witnessed fall by EMS crew when they arrived to transport the patient to the hospital ED. Patient #1 had diagnoses which included stomach cancer, hypertension and diabetes, with increased generalized weakness the past 2 weeks. Patient #1 was hypoxic on room air, and an Xray revealed lower lobe infiltrates (pneumonia). Patient #1 was admitted to the hospital on 2/17/2021 at 7:48 AM.

Review of the nursing skin assessments conducted twice daily from 2/17/2021 through 2/21/2021 revealed no documentation of bruising for Patient #1.

Patient #1 was discharged home to the care family on 2/21/2021 at 12:18 PM. Patient #1 was transported home via stretcher with ground ambulance transportation.

3. The family of Patient #1 contacted the hospital to file a grievance on 2/21/2021 regarding multiple bruising noted when Patient #1 arrived home. The family provided photos to the hospital Director of Risk Management. The surveyor obtained copies of the photos of Patient #1 on 3/3/2021. The photos revealed a bruise to the left eye and cheek area, and multiple bruises to his right wrist, forearm and upper arm.

4. In a telephone interview on 3/4/2021 at 9:27 AM with Nurse #1, who discharged Patient #1 on 2/21/2021, the nurse stated she cared for Patient #1 on 2/20/2021 and 2/21/2021. Nurse #1 verified she completed Patient #1's discharge assessment and paperwork. Nurse#1 stated she recalled Patient #1 had some generalized bruising to his skin and maybe some bruising on his left eye. When asked why she did not document the bruising the nurse stated, "I can't recall if I documented it, but if it's not there then yes...I didn't document..." Nurse #1 was asked where it should have been documented, and the nurse verified the skin assessment forms had an option to document bruising.

In an interview in the hospital conference room on 3/3/2021 at 11:00 AM, the Director of Risk Management and the Administrative Director of Nursing verified the failure to document the bruising for Patient #1 was "not acceptable"

In a subsequent interview on 3/3/2021 at 11:20 AM, the Administrative Director of Nursing demonstrated how nursing staff could and were expected to document bruising in the skin assessment section of the electronic medical record.

The hospital nursing staff failed to follow written hospital protocols to accurately document the skin condition for Patient #1.