HospitalInspections.org

Based on document review and interview, the registered nurse failed to ensure skin assessments were completed and documented every eight (8) hours, failed to ensure turning/repositioning was completed/documented every two (2) hours and failed to ensure a wound evaluation was completed/documented within twenty-four (24) hours of admission for one (1) of ten (10) patients. (Patient # 10)

Findings include:

1. Review of the facility policy titled, "Patient Admission, Assessment, Reassessment and Documentation Guidelines, and Vital Signs Procedures", policy number NSI-ACT_30, indicated patient assessments must be documented every eight (8) hours and wounds should be documented within twenty-four (24) hours of admission. This policy was last revised in 02/2021.

2. Review of the facility policy titled, "Skin and Tissue Inspection, Assessment and Management Procedure", policy number NSI-ACT_60, indicated to perform measurements of wounds on admission and turn/reposition a patient every two (2) hours. This policy was last revised in 07/2021.

3. Review of patient # 10's medical record (MR) indicated the following:
a. Review of the closed MR for patient # 10 indicated the patient was a 78 y/o (year/old) seen at H # 2's Emergency Department (ED) on 02/24/2022 when he/she was admitted. The patient remained in the ED until being moved on 02/27/2022 to a bed on an inpatient unit.
b. The patient was placed on a hospital bed on 02/26/2022. The MR lacked any ED skin assessments and/or turn every two (2) hour documentation from 02/24/2022 - 02/27/2022 at midnight.
c. The patient was transferred to the inpatient unit on 02/27/2022 at approximately 12:46 am. Physician order dated 02/27/2022 indicated for a wound/ostomy evaluation and treatment. The MR lacked the evaluation documentation.
d. The MR lacked a nursing skin assessment at 11:00 am and 6:00 pm on 03/05/2022.
e. The MR lacked every two (2) hour turns on 03/07/2022 at 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 4:00 pm and 6:00 pm.
f. The MR lacked every two (2) hour turns on 03/08/2022 at 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm and 6:00 pm.
g. The MR lacked every two (2) hour turns on 03/09/2022 at 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm and 6:00 pm.

4. In interview dated 04/27/2022 at approximately 3:00 pm with A # 4 (Director of Critical Care), confirmed the patient should have been seen by the wound care nurse within 24 hours of admission to H # 2. The ED staff do not document on flowsheets for skin/turning/repositioning. The patient should have had their skin assessed every eight (8) hours and repositioned/turned every two (2) hours throughout their inpatient stay.