HospitalInspections.org

Based on document reviews, interviews, and policy reviews, the nursing staff failed meet the medical needs of the patient and failed to include the patient's medical findings on the initial nursing treatment plan.

Findings were:

Facility document entitled "Treatment Planning" states in part, "Definitions Initial Treatment Plan is formulated by the admitting Nurse and found in the Nursing assessment portion of the Integrated Assessment. It is good for the initial 72 hours, 7 or 30 days of treatment (see below), at which time the Interdisciplinary Master Treatment Plan is developed.
Procedure: #2. The treatment planning process begins at admission with the initial treatment plan being completed upon admission with strategies for the care and treatment of patients during the evaluation process. It is located in the patient's medical chart with the Integrated Assessment."

Nursing Assessment document date 9/18/2018 at 1730 revealed the following:
Skin Assessment diagram documentation/marked as followings:
Anterior (body) diagram:
Left cheek/neck, right forearm, lower outer legs and left knee and thigh "Scratch from dog"
Bruises to bilateral antecubital area, and left thigh and lower leg.
Sores to pubic area
Scar to upper left upper and lower arm.
Posterior (body) diagram:
Scar on right elbow.
Sores to buttocks and thigh at creases.

Initial Treatment Plan (Nursing) date 9/18/18 1800, problem list did not include skin integrity, sores on the pubic area and buttocks and thigh or other skin breakdown.
No documented evidence was observed that nursing staff performed a reassessed until 4-5 day later, at which point rash/sores had spread to other body areas.
The above findings were confirmed by the Infection Control Nurse on the morning of 10/10/2018.

Based on medical record review it was determined that the physical assessment performed on the patient 24 hours with admission to the hospital was not accurate.

Finding were:

The patient's History and Physical Examination, Date: 9/19/18 Time:1130 completed by Staff #13 was not accurate. The following was documented: Skin section: marked-no rash or wound observed "Dry, warm."
The above finding was confirmed by the Risk Manager the afternoon of 10/10/2018.