HospitalInspections.org

Based on document review and interview nursing failed to ensure that a skin evaluation/assessment was completed every 12 hours in 2 (Patients 6 and 8) of 10 patient's medical record reviews.

Findings Include:

1. Review of policy titled: Skin/Pressure Ulcer Assessment and Prevention last revised 07/2018, indicated that assessment for skin breakdown is to be completed every 12 hours if the assessment score is in the low or moderate risk category and every 8 hours if the assessment score is in the high risk category.

2. Review of Patient 6's medical record indicated patient had bilateral bruising on arms/hands and a skin tear between thighs documented at admission on 09/10/19. The admission skin risk assessment was low risk. The Daily Nursing Assessment lacked documentation of skin assessments in one 12 hour time period for 09/11, 09/14, 09/15, 09/16, 09/17, 9/22, 09/25, 09/26 and 09/27 of 2019 (all night shifts).

3. Review of Patient 8's medical record indicated patient had skin tear above right eye, bilateral bruising on lower arms and a bruise on right lower leg documented at admission on 09/17/19. The admissionskin risk assessment was low risk. The Daily Nursing Assessment lacked documentation of skin assessments from 09/18/19 through to discharge date of 10/01/19.

4. Interview with P52 (Interim Director of Nursing) on 10/16/19 at 3:05 pm indicated that Patient 6's medical record was missing documentation of completed skin assessments.

5. Interview with P52 (Interim Director of Nursing) on 10/16/19 at 3:05 pm and at 5:00 pm confirmed that the expectation was for nursing to document a head-to-toe skin assessment every shift (every 12 hours).

6. Interview with P50 (Director of Operations) on 10/16/19 at 4:49 pm confirmed that Patient 8 lacked further documentation of skin assessments after admission on 09/17/19 through discharge on 10/01/19.