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NIAGARA FALLS MEMORIAL MEDICAL CENTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on medical record review and document review, nursing services failed to accurately evaluate Patient #1's skin integrity from 2/13/10 to 2/22/10.
Findings Include:
Review of policy "Nursing Care Guidelines: Impairment of Skin Integrity" last revised 2/08 revealed patients that are at risk for skin breakdown will be reassessed every 48 hours and with any change in condition using the Modified Braden Scale. This is to be documented on the Pressure Ulcer Risk Assessment Form (UOC #796). A change in condition includes but not limited to: a surgical procedure, not eating, change in mobility, incontinence and transfer to the ICU. Assess skin integrity of all skin surfaces every 2 hours, nutritional intake every 8 hours, hydration status and peripheral and/or generalized edema.
Review of the Admission Assessment dated 2/12/10 revealed Patient #1's skin is pale and dry. No evidence of skin breakdown is listed.
Review of the Plan of Care dated 2/13/10 to 2/14/10 revealed a plan to maintain skin integrity. Observe all skin surfaces every 2 hours. Assist the patient to change position every 2 hours. Reassess patient for risk of skin breakdown weekly and with any change in condition.
Review of Activity Report dated 2/16/10 at 0730 revealed coccyx area darker and redder with Allevyn intact. At 1100 the Allevyn on Patient #1's coccyx is intact.
Review of the Peri-Operative Transfer Summary dated 2/19/10 at 1627 revealed skin is warm and dry, no decubitus and a dressing on the right hip.
Review of Activity Report dated 2/22/10 at 0730 revealed rectal area is reddened and coccyx area has deep purple tissue damage with superficial open areas. Consult for skin care nurse called.
Review of the Skin Care note dated 2/23/10 at 1040 revealed an open area on sacrum approximately 5cm x 3cm x 0.4cm depth. The area is unstageable, surrounding tissue with areas of deep tissue damage.
No evidence was found to indicate nursing staff assessed Patient #1's sacral area from 2/13/10 to 2/16/10. On 2/16/10 staff noted a change in Patient #1's skin integrity but there is no evidence of a complete skin assessment and/or skin consult.