HospitalInspections.org

Based on record review and interview, the hospital failed to ensure evaluation of skin alteration for two (Patient #2 and #4) of five patients.

This failed practice has the likelihood to place patients at risk of delayed recognition of clinical changes.

Review of policy titled "Nursing Documentation" read in part, "documentation is any pertinent information about the patient and should be meaningful to others. ...Documentation includes: ...monitoring of the patient's condition, and any significant change in the patient's condition."

Patient #2

Review of 08/10/21 3:20 PM restraint flowsheet read in part "noted change in skin color ...skin pigmintation [sic] reported" and showed no documentation to describe the change in skin color or its location.

Review of 08/10/21 6:40 PM nursing progress note read in part "facial and neck discoloration" and showed no documentation to describe the laterality, location, color or size.

Review of 08/11/21 5:07 PM plan of care read in part, "bruising on ...face" and showed no documentation of laterality, location, color or size.

Review of 08/12/21 12:45 PM nursing progress note read in part, "petechiae and purplish coloring on ...face and neck" and showed no documentation of laterality, location or size.

On 09/02/21 at 9:11 AM, Staff F reviewed the medical record for Patient #2 and stated documentation of skin alteration should have included identification of location so monitoring for change in condition could occur.

Patient # 4

Review of 04/26/21 4:56 PM nursing progress note read in part, "scratching ...arm until bleeding" and showed no documentation of laterality, location, size of wound, amount of drainage, or application of dressing.

Review of 04/27/21 5:28 PM plan of care read in part, "scratching ...arms" and showed no documentation of location, size of wound, presence or absence of drainage, or application of dressing.

Review of 04/28/21 2:17 PM nursing progress note read in part, "scratching ...arm" and showed no documentation of laterality, location, size of wound, presence or absence of drainage, or application of dressing.

Review of 05/03/21 6:46 PM progress note read in part, "scratch ...arm" and showed no documentation of laterality, location, size of wound or amount of drainage.

On 09/02/21 at 11:53 AM, Staff F reviewed the medical record for Patient #4 and stated best practice would have been to describe size, color, drainage, or requirement of dressing or intervention for wounds.