HospitalInspections.org

Based on record review and interview, the hospital failed to ensure evaluation of skin alteration for one (Patient #14) of 17 patent records reviewed.

Findings:

Review of policy titled "Documentation Standards Guideline" read in part, "Nursing Documentation Guidelines ...nursing documentation will include assessment findings WDL, with additional documentation focused solely on exceptions or deviations from the expected outcomes."

Review of policy titled "Skin Care for Adults" read in part, "assessment and documentation of all wounds will be completed every shift, and with every dressing change, including status/integrity of dressings if present."

PATIENT #14

Review of the medical record showed the patient came to the ED on 02/11/25 with a wound and did not show documentation of a nursing assessment to enable the monitoring of wound characteristics such as location, size, color of wound bed, presence or description of drainage or odor. Specifically:

On 02/11/25 at 11:34 AM, the patient arrived to the ED with a chief complaint of right leg pain related to a wound. Nursing documentation related to the wound read in part, "pain to wound on [the patient's] incision on right leg ...dressing cover applied to wound."

On 03/31/25 from 8:33 AM to 8:57 AM, Staff M reviewed the medical record and stated:
1. Documentation in the skin assessment flowsheet was expected to be done and was not.
2. Documentation of the supplies used to dress a wound was expected to be done and was not.

Based on record review and interview, the hospital failed to ensure adherence to policy for two (Patients #1 and #16) of 17 patient records reviewed.

Findings:

PATIENT #1

Review of Attachment F of policy titled "Required Elements of Daily Assessment/Reassessment" read in part, "ADULT ...VITAL SIGNS ...At time of triage and then at a minimum of every 2 hours on medical patients with an ESI of 1-3."

Review of the medical record showed an approximately three and a half hour ED visit and did not show documentation of vital signs every two hours. Specifically:

On 02/11/25 at 12:04 PM, the patient arrived to the ED with a chief complaint of allergic reaction. Triage began at 12:09 PM and the patient was given an emergency severity index (ESI) of 3. Vital signs were obtained at 12:11 PM and at time of discharge at 3:34 PM ( more than 1 hour 15 minutes past due).

On 03/31/25 at approximately 1:05 PM, Staff M reviewed the medical record and stated:
1. More than two hours lapsed between vital signs.
2. Vital signs were due every two hours.
3. The risk to the patient was unrecognized decompensation or anaphylaxis.


PATIENT #16

Review of policy titled "Emergency Department Arrivals, Triage, and Waiting Population" read in part, "Persons who are deemed appropriate to wait may be returned to the lobby when the ED is at capacity ...The waiting population will be reassessed by direct visualization at a minimum of every 2 hours."

Review of policy titled "Patient Leaving Against Medical Advice, Leaving Before Being Evaluated or Discharged, Patient Elopement and Abduction" read in part, "Patient Left Without Being Evaluated ...If the patient left without notifying staff ...or was not visualized leaving: Attempt to locate the patient at least three times before discharging the patient from the system. Attempts will be documented with in the electronic health record."

Review of the medical record showed an approximately four hour ED visit after triage with a disposition of ''left without being evaluated' and showed no documentation of visualization every two hours. Specifically:

On 02/10/25 at 10:09 AM, the patient arrived to the ED with a chief complaint of dizziness. Triage was completed at 10:15 AM with an ESI of 3. At 2:05 PM, a patient disposition and comment was documented as "LWBE (Left without being evaluated) Pt left without being evaluated after triage."

On 03/31/25 at approximately 9:11 AM, Staff M reviewed the medical record and stated:
1. There was no documentation anyone ever looked for the patient to make sure the patient had not passed out somewhere.
2. Not visualizing the patient every 2 hours after triage posed a risk of a fall, stroke or death.