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UW HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, it was determined for 1 of 3 (Pt. #1) clinical records reviewed for wound assessment, the Hospital failed to ensure a nursing skin assessment was done as required.
Findings include:
1. On 3/15/16 at approximately 12:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a 60 year old male admitted on 2/20/16 with diagnoses of altered mental status and urinary tract infection. The Nurses' Head to Toe assessment on 2/20/16 at 2:21 AM by the registered nurse (RN #4) indicated, "... Integumentary Parameters: no signs/symptom, normal skin color, skin intact..."
2. The policy titled "Pressure Ulcer Prevention and Treatment" (effective 4/7/15) required, "... The physical assessment will be done to include alterations in skin... change in color such as red, blue or purplish hues..."
3. On 3/17/16 at approximately 11:05 AM, an interview was conducted with RN #4 who stated that he remembered Pt. #1 having a bruise on his right buttocks. However, RN #4 stated he did not document the bruise. RN #4 added that, "I should have documented Pt. #1's bruise on his right buttocks."