HospitalInspections.org

Based on record review, observation, document review, and staff interview, it was determined the facility failed to follow procedures for completing nursing assessments in one (1) out of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. The patient was admitted directly to Unit 6 front (6F) on 09/28/22 as a transfer from an outside facility for fluid overload related to end stage renal disease and noncompliance with dialysis treatments. All nursing shift assessments documented under skin state "WDL" (within defined limits). On 10/03/22 at 9:33 a.m., the patient fell from a standing position at the side of the bed. Physician #1 was notified, and a Computed Tomography (CT) scan of the head, and an x-ray of the left shoulder were ordered. An assessment was documented by Registered Nurse (RN) #3 after the fall, which noted the patient had areas of discolored/purple skin. The patient remains hospitalized on Unit 6F.

The patient was transferred from another facility in which an Emergency Department (ED) Provider note on 09/27/22 states in part: "Physical Exam ... Abdominal: ... Comments: Diffuse ecchymosis [a small bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes] noted over abdomen."

An observation was conducted of patient #1 on Unit 6F, Room 633 on 10/04/22 at approximately 2:45 p.m. There was noted ecchymosis over the patient's left upper arm, onto the left anterior shoulder. The patient had diffuse ecchymosis across the entire lower abdomen, which appeared to be healing.

A review was conducted of a policy titled "Patient Assessment and Reassessment," last revised 06/30/21. The policy states in part: "A. Initial Patient Assessment ... 3. The full admission assessment is to be completed in its entirety within four (4) hours of arrival on the assigned unit ... B. Reassessment 1. Reassessment is done every 12 [twelve] hours or per a department specific policy."

An interview was conducted with RN #2 on 10/03/22 at 2:22 p.m. When asked about the bruising, RN #2 stated, "[Patient #1] is a dialysis patient. I don't remember specifically seeing any bruises. I would hope I would have documented it if I saw bruises."

A telephone interview was conducted with RN #1 on 10/04/22 at 11:11 a.m. RN #1 remembered patient #1 and stated, "I don't remember seeing anything abnormal on [patient #1's] arm or any bruising."

An interview was conducted with RN #6 on 10/04/22 at 2:16 p.m. Regarding patient #1, RN #6 stated, "I remember the patient's left arm was bruised, and I had talked to the dialysis nurse. [Dialysis Nurse] said it wasn't anything out of the ordinary. I should have documented it though - you just click bruises in the assessment."

On 10/04/22 at approximately 4:00 p.m., the Regulatory Compliance Coordinator confirmed there was no skin abnormalities documented in patient #1's medical record prior to 10/03/22.

A telephone interview was conducted with the Clinical Coordinator, Interim Nurse Manager of Unit 6F on 10/04/22 at 4:35 p.m. Regarding skin assessments, the Interim Nurse Manager stated, "When you do your head-to-toe assessment it isn't an entire assessment. If any abnormality, it should be documented. The patient had bruises anywhere, it definitely should have been documented. There's a spot in the record that you can document bruising ecchymosis, the location, and you can always comment or put in the nursing note. I can't say we have had an issue before with skin assessment documentation."