HospitalInspections.org

The hospital reported a census of 36 patients. Based on record review and staff interview the hospital failed to identify and evaluate problems and take steps to insure a safe patient environment to protect vulnerable patients from developing hospital acquired skin problems for 2 of 20 sampled patients (#1 and #18).

Findings include:

- Review on 4/19/11 at 8:30am of the hospital policy "Skin Risk Assessment and Management" directed "...When there is an alteration in skin integrity, notify the Infection Control Coordinator or the Certified Wound Care Nurse ...documentation ...size: width, length, and depth ....color of surrounding tissue...location of wound ..."

- Patient #1's medical record reviewed on 4/12/11 at 9:00am revealed an admission date of 3/30/11 with a diagnosis of Urosepsis (infection in the urinary tract leading to a poisoning of the blood) and Hypokalemia (low potassium levels). The admission nursing assessment dated 3/30/11 at 7:20pm indicated the patient's skin was warm, pale, intact without redness. The Braden scale (used to assess potential skin risks) rated the patient as high potential for skin breakdown. The on-going assessment of the nursing care plan goal #9 on 4/1/11 at 6:16 am documented no sign or symptoms of skin breakdown bruise to left side of back. Throughout patient #1's stay in the hospital from 3/30/11 to 4/5/11 the nursing assessment failed to document an assessment of patient #1's bruise to the left side of back that included the size, width, length and color of the bruise.

Review of documentation and pictures on 4/14/11 between 8:00am and 11:00am revealed patient #1 had a purple colored bruise across the left side of the back.

Patient #1 observed on 4/18/11 at 11:30am at another facility revealed a fading bruise across left side of the back measuring 6 ? inches by 2 inches with a slightly darker area toward the middle back, round baseball shaped.

Administrative staff A and administrative staff B interviewed on 4/18/11 at 10:45am acknowledged the facility staff failed to document and evaluate bruises on patient #1.

- Patient #18's medical record reviewed on 4/13/11 at 2:45pm revealed an admission date of 4/5/11 with a diagnosis of right interthrochantric hip fracture (a fractured right hip). The admission nursing assessment on 4/5/11 at 9:55am indicated the patient's skin was intact (no broken areas). The Braden scale rated the patient as at risk for skin breakdown. Throughout patient #18's stay in the hospital from 4/5/11 to 4/11/11 the nursing skin assessment documented patient #18's skin as warm, dry and intact.

Review on 4/18/11 at 12:00pm of documentation at another facility revealed patient #18 returned to their facility on 4/11/11 with a stage 1 pressure ulcer 1cm (centimeter) to the left buttock and a stage 2 pressure ulcer 0.25cm to the left buttock.

The hospital failed to ensure patients received safe nursing care, providing ongoing assessments and monitoring patient care to prevent patient #1's bruise to the left side of back and patient #18's stage I and stage II hospital acquired pressure sore of the left buttock.

The hospital reported a census of 36 patients. Based on observation, record review and staff interview a RN (register nurse) failed to consistently implement established hospital policies to prevent development of skin problems and evaluate the patient's health status for 2 of 20 sampled patients (#1 and #18).

Findings include:

- Review on 4/19/11 at 8:30am of the hospital policy "Skin Risk Assessment and Management " directed " Patients will be assessed on admission...re-assessment for alteration in skin integrity will be completed every shift ...When there is an alteration in skin integrity, notify the Infection Control Coordinator or the Certified Wound Care Nurse ...documentation ...size: width, length, and depth ....color of surrounding tissue...location of wound ..."

- Patient #1's medical record reviewed on 4/12/11 at 9:00am revealed an admission date of 3/30/11 with a diagnosis of Urosepsis (infection in the urinary tract leading to a poisoning of the blood) and Hypokalemia (low potassium levels). The admission nursing assessment dated 3/30/11 at 7:20pm indicated the patient's skin was warm, pale, intact without redness. The Braden scale (used to assess potential skin risks) rated the patient as high potential for skin breakdown. The on-going assessment of the nursing care plan goal #9 on 4/1/11 at 6:16 am documented no sign or symptoms of skin breakdown bruise to left side of back. Throughout patient #1's stay in the hospital from 3/30/11 to 4/5/11 the nursing assessment failed to document an assessment of patient #1's bruise to the left side of back that included the size, width, length and color of the bruise.

Review of documentation and pictures on 4/14/11 between 8:00am and 11:00am revealed patient #1 had a purple colored bruise across the left side of the back.

Patient #1 observed on 4/18/11 at 11:30am at another facility revealed a fading bruise across left side of the back measuring 6 ? inches by 2 inches with a slightly darker area toward the middle back, round baseball shaped.

Administrative staff A and administrative staff B interviewed on 4/18/11 at 10:45am acknowledged the facility staff failed to follow the hospital's policy and document the size, width, and length and color of the bruise on patient #1's back.

- Patient #18's medical record review on 4/13/11 at 2:45pm revealed an admission date of 4/5/11 with a diagnosis of right interthrochantric hip fracture (a fractured right hip). The admission nursing assessment on 4/5/11 at 9:55am indicated the patient's skin was intact (no broken areas). The Braden scale rated the patient as at risk for skin breakdown. Throughout patient #18's stay in the hospital from 4/5/11 to 4/11/11 the nursing skin assessment documented patient #18's skin as warm, dry and intact.

Review on 4/18/11 at 12:00pm of documentation at another facility revealed patient #18 returned to their facility on 4/11/11 with a stage 1 pressure ulcer 1cm (centimeter) to the left buttock and a stage 2 pressure ulcer 0.25cm to the left buttock.

The hospital failed to insure a RN consistently implement established hospital policies to prevent development of skin problems and evaluate the patient's health status for patients #1 and #18.