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Based on review of facility policy and procedure, medical records (MR) and interview with staff (EMP), it was determined that nursing failed to provide a nursing care plan for skin integrity related to the patient's constant movement for one of 10 medical records reviewed (MR1).

Findings include:

Review of the facility's policy "Skin Tears Assessment, Prevention Treatment," reviewed October 2010, revealed "General Information: Skin Tears are traumatic wounds caused by friction and shear. Patients admitted to Moses Taylor Hospital will be assessed for the presence of skin tears, identified as being at risk, be assessed every shift to monitor development and initiate treatment. Guidelines: A. Assessment-Identifying Patients at Risk: 1. A risk assessment will be performed by an RN (Registered Nurse) on admission and every shift thereafter by a RN/LPN (Registered Nurse/Licensed Practical Nurse). 2. ... the following risk groups will be used to identify patients at risk and develop a plan of care. Patient Risk Groups 1. Any patient with a skin tear. 2. Patient with advanced age greater that 75 years of age. 3. Patient with bruised, open lesions, 3 or more senile purpura, dry scaly skin. 4. Patient with PVD (Peripheral Vascular Disease) or neuropathy. 5. Patients with contractures, hemiplegia/hemiparesis. 6. Patients confined to bed or wheelchair/chair. 7. Patients with impaired cognitive ability."

Review of MR1 on April 1, 2011, revealed no documentation of a nursing care plan initiated for this patient identified with a shearing type skin breakdown.

Interview with EMP1 confirmed that this patient had been identified at risk for skin breakdown and no care plan for impaired skin integrity had been initiated. EMP1 confirmed that the wound care nurse was consulted, and recommendations were made for skin breakdown. There was no documentation that a care plan for impaired skin integrity had been initiated.