HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure medical records documented information necessary to monitor the patient's condition, by failing to photograph skin integrity issues per facility policy.

Findings included:

Facility Based Policy entitled, "Tissue and Pressure Ulcer Management" stated in part,
"POLICY: Guidelines are established to: ...

o Ensure comprehensive assessment, documentation and accurate description of pressure ulcer ....
I. Assessment ...

B. At the time of the patient admission, the RN will ensure:
1. Objective assessment data collection that is based on a systematic tissue assessment including:
a. Tissue Color
Describe the color of the tissue. Include any notation of cyanosis, jaundice, pallor, bruising, uneven pigment distribution, or any area of discoloration.
b. Tissue Condition, especially over bony prominences. Describe the condition of the tissue. Include the intactness; temperature; moisture/dryness; consider the turgor, elasticity; note any break in tissue integrity and/or trauma such as abrasions, tissue tears, insect or other bites, edema, surgical or other wounds including pressure ulcers; note any scars and any areas with exudate and describe ...
d. Inspection Under Dressings
Any dressing found at the time of admission will be removed (utilizing appropriate technique in accordance with standards of care) and the condition of the tissue covered by the dressing will be assessed and documented. Wet to dry dressing applied after visualization and pictures are taken ...

3. Documentation of Assessment
a. Documentation will be on the appropriate computer documentation form to include identification of abnormal skin conditions including pressure ulcers and wounds, and location of such abnormal skin condition. Obtain photo documentation of all pressure ulcers and/or wounds and ensure placement in the medical record. (See Addendum C) ..."

Review of 10 patient records 5 of 10 patients did not have their skin issues photographed when initially identified, photographs were documented days and or weeks after identification of the skin issue.
* Patient #3 had the following skin integrity issues noted:
01/11/25 Pressure Injury to the Sacrum was noted. 01/13/25 at 0800 IV Infiltrate wound to the Left Arm was noted. 01/25/25 at 0800 a right heel deep injury was noted. 01/25/25 at 1500 an Abdominal Surgical Wound was noted.
Photo Documentation was present: 01/31/25 at 1334 for the abdominal wound. 02/05/25 at 1032 and 1124 for the upper arm infiltrate wound. There was no photograph documentation of the right heel deep tissue injury.
* Patient #7 had the following skin integrity issue noted:
01/31/25 at 1tissue 300 Left Hip Wound was noted Eschar, Necrotic. Packing in place. Clean Dry and Intact (CDI). Wound Vacuum was changed.
Photo Documentation was present: 02/05/25 at 1121 for left hip wound.
* Patient #10 had the following skin integrity issue noted:
02/01/25 at 2000 a Surgical Site Abdominal Midline with foam dressing in place. CDI. Wound Vacuum in place.
Photo Documentation was present: 02/05/25 at 1126.
* Patient #11 had the following skin integrity issue noted:
01/12/25 at 0800 Pressure Injury Coccyx Stage 2 pressure injury with foam dressing in place, CDI.
Photo Documentation was present: 01/22/25 on 0537 and 01/25/25 at 1529.
* Patient #12 had the following skin integrity issues noted:
01/17/25 at 1928 Fistula to the coccyx noted, unstageable soughing with eschar. Kerlix in place.
01/17/25 at 1930 Left Posterior Shoulder Skin tear present on arrival, noted to be pink, red, with dressing in place.
01/17/25 at 1920 Right elbow skin tear present on arrival, noted to be pink and red, with foam dressing in place.
Photo Documentation of the coccyx fistula was present on 01/22/25 at 1156, 01/27/25 at 1159, and 02/05/24 at 0958.

By failing to photograph the skin integrity issues when initially noted, it is difficult to gauge whether the skin issues are improving or worsening over time. Photographs are an effective method to monitor the patients skin condition over time. In interview on 02/11/25, staff members # 2 and 3 verfied the facility was not following their policy to photograph skin integrity issues.