HospitalInspections.org
Bringing transparency to federal inspections
SINAI-GRACE HOSPITAL
NURSING CARE PLAN
Tag No.: A0396
Based on document review and interview, the facility failed to follow policy and ensure that nursing staff implemented an updated Nursing Care Plan (NCP) for 1 of 3 (P-1) inpatients resulting in an increased potential for skin break down. Findings include:
Record review for P-1 conducted on 9/11/23 at 1300 and again on 9/12/23 with the assistance of Staff E revealed that no skin integrity NCP or risk for impaired tissue integrity NCP was initiated by nursing. Braden scale assessments on admission 10/19/2022 and throughout stay indicated P-1 was a high risk for skin breakdown (scoring at 15 -16). P-1 needed assistance with toileting due to decreased mobility and morbid obesity (524 lbs.) and was admitted with a complicated urinary tract infection after failed outpatient treatment (with incontinence). P-1 was using topical miconazole powder 2% (medicated powder to treat and prevent skin breakdown) to skin folds at home prior to admission. Infectious disease provider documentation on 11/1/22 revealed, P-1 complained of vaginal burning and upon examination a small vulvar laceration without drainage was noted (most likely moisture related), and that P-1 was instructed to keep area clean and dry. A provider pressure ulcer prevention order set was activated on 11/3/2022. Nursing documentation of 11/5/22 at 1000 revealed a local rash on inner-buttock.
Interview with RN Manager Staff K revealed that if patient did not have a pressure ulcer, a Care Plan for skin integrity may not necessarily be needed.
Policy, "Skin and Wound Care Flow Charts" dated 7/21/21, states under heading: Flow chart Braden Scale: "All patients who have a Braden Score of 18 or below must have interventions initiated ...Initiate a Plan of Care for Risk for Impaired tissue integrity."
Policy titled, "Pressure Injuries: Prevention and Care", dated 8/10/21, states under RN responsibilities #7: "Document in Altered Tissue Integrity Plan of Care every shift for patients with ...at risk for pressure injuries based on low subscales or Braden Scale© Score < 18.