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Based on record review and interview, the facility failed to ensure that one of 6 sampled patients was assessed to reflect the condition of patient's skin on admission. (Patient 2 ) This had the potential for ongoing assessments by licensed staff to be incorrect and increased the risk of the harmful complication by not being able to reference the skin's appearance.

Findings:

During a review of Patient 2's medical record, admission documentation indicated that she was admitted on 5/27/13, with a diagnosis of cellulitis (diffuse inflammation/infection of the connective tissue) of the left arm.

A hospital form titled, "Body Checklist" documented that Patient 2 had two intravenous sites (tubing inserted into a vein to allow fluids to be administered) on the right arm but did not document that Patient 2 had anything on her left arm.

The location and the description of the redness on Patient 2's left arm, caused by the cellulitis, was not noted on the "Body Checklist." The notation of redness and the measurement of the initial redness would be important to be able to assess the extent of her inflammatory process as it appeared on admission. The initial measurements would then be compared to all future assessments of the cellulitis site by documenting the growth of the redness (which would indicate the cellulitis was worsening) or the shrinkage of the redness (which would indicate the treatments were working and the cellulitis was resolving).

During an interview on 5/29/13 at 10:50 am, the Chief Nursing Officer (CNO) confirmed that the hospital form titled "Body Checklist" was incomplete.