HospitalInspections.org

Based on medical record review, review of hospital policy and staff interview it was determined the registered nurse (RN) failed to initiate the skin care protocol per policy for eight (8) of eleven (11) medical records reviewed for skin care (patient #1 A & B visits, patients # 2, 3, 4, 5, 8 and 9). This failure has the potential to adversely affect the care and condition of all patients with skin care needs. Findings include:

1. Review of the medical record for patient #1 (A visit) revealed the patient developed skin breakdown during hospitalization from 12/2 through 12/17/08. Review of the record revealed no order for the skin care provided by nursing staff .

2. Review of the medical record for patient #1 (B visit) revealed the patient was readmitted on 1/21/09 with multiple areas of skin breakdown. Review of the record revealed no order was obtained for the skin care provided by nursing staff until 2/3/09.

3. The policy "Pressure Sore Prevention/Management," reviewed 10/07, was provided for review. The policy notes the following under the Wound Care/Dressings section: "Follow physician orders or the SMMC (St Marys Medical Center) Skin Care Protocol or the Pressure Ulcer Protocol. Re-evaluate treatment plan if the pressure ulcer shows no evidence of healing within 2 weeks."

The Skin Care Protocol, revised 2/07, was provided for review. The Protocol is a preprinted order set which addresses: A. Red Areas - Intact Skin, B. Minor Dry Wounds, C. Moist Wounds: Lightly Exuding and D. Moist Wounds: Moderate to Heavy Exuding. The form requires the signature of the ordering physician and the nurse taking and/or signing off the order.

During the morning of 1/6/10, both records of patient #1 were reviewed and discussed with both the Clinical Manager and Charge Nurse of the Medical Intensive Care Unit (MICU). The above referenced policy and protocol were also reviewed and discussed. The Clinical Manager acknowledged the RN failed to initiate the Skin Care Protocol and obtain an order for the skin care provided during the A visit and failed to initiate the Skin Care Protocol or obtain an order for skin care until 2/3/09 during the B visit.

4. Review of the current medical record for patient #2 revealed on 12/4/09 the RN first documented skin redness on the buttocks and on 12/9/09 applied a dressing to the affected skin. Review of the Skin Care Protocol reveals it was not initiated by the RN until 12/18/09, two (2) weeks after the skin redness was first identified.

5. Review of the current medical record for patient #3 revealed on 1/5/10 the RN documented the buttocks was reddened. At 0100 on 1/6/10, the RN documented the area was purplish with broken skin and a dressing was applied. Review of the Skin Care Protocol reveals it was not initiated by the RN until 1/6/10 at 1335.

During the afternoon of 1/6/10, these records were reviewed and discussed with the Clinical Manager of the Cardiovascular Intensive Care Unit. She acknowledged the RN failed to initiate the Skin Care Protocols per policy.

6. Review of the medical record for patient #4 revealed the RN first documented skin redness on 1/2/10, applied a dressing on 1/4/10 and documented the patient developed another area with a blister on 1/5/10. Review of the Skin Care Protocol revealed it was not initiated by the RN until 1/6/10 at 1400.

7. Review of the medical record for patient #5 revealed the RN documented skin redness developed on 12/28/09. Review of the Skin Care Protocol revealed it was not initiated by the RN until 1/6/10 at 1430.

During the afternoon of 1/6/10, these records were reviewed and discussed with the Charge Nurse of the Neurotrauma Intensive Care Unit. He acknowledged the RN failed to initiate the Skin Care Protocols per policy.

8. Review of the medical record for patient #8 revealed the RN documented skin redness developed on 1/3/10. Review of the Skin Care Protocol revealed it was not initiated by the RN until 1/5/10.

9. Review of the medical record for patient #9 revealed the RN documented skin redness was present at time of admission at 0700 on 1/3/10. Review of the Skin Care Protocol revealed it was not initiated by the RN until 1/4/10.

During the afternoon of 1/6/10, these records were reviewed and discussed with the Charge Nurse of the MICU. She acknowledged the RN failed to initiate the Skin Care Protocols per policy.

Based on medical record review and staff interview, it was determined the hospital failed to ensure one (1) of eight (8) closed medical records reviewed was completed within thirty (30) days following discharge (patient #1, B visit). This delay in completion has the potential to adversely affect the accuracy and availability of the record.

Findings include:

1. A review of the medical record for patient #1, B admission (1/21-4/27/09), revealed the patient expired on 4/27/09. The Death Summary was not dictated until 1/5/10, one (1) day after the record was requested for review.

2. A phone interview was conducted with the Director of Health Information Management in the afternoon of 1/5/10. She acknowledged the Death Summary was not dictated until eight (8) months after patient #1 expired. She then stated the expectation was that all discharge/death summaries be completed in thirty (30) days.