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Based on record review and staff interview, it has been determined that the facility failed to provide nursing care in accordance with accepted standards of nursing practice and hospital policy for 3 of 7 patients reviewed, Patient ID #'s 1, 4 and 7 related to full body skin assessments.

Findings are as follows:

Review of the hospital's policy titled, "Patient Care Services Pressure Injury Prevention and Treatment Policy" dated April 8, 2020 states in part,
"V. Procedure.
A. Assessment
i. The Braden Scale and a full body skin assessment will be completed on all patients within 24 hours of the admission or observation order, upon transfer from another unit, with a significant change in condition and post operatively and prior to discharge.
ii. For all admissions and transfer from other units, a two-nurse skin assessment and sign off is required.
iii. The Braden Scale and a full body skin assessment will be completed daily on all patients."

Review of a complaint dated 3/22/2023, reports Patient ID # 1, was readmitted to the psychiatric hospital after an acute hospital stay from 3/9/2023 through 3/21/2023 for medical concerns. Upon re-entry to the psychiatric hospital on 3/21/2023, a full skin assessment was completed, and the patient was noted to have multiple bruises of unknown origin.

1. Review of the record for patient ID # 1, who was transferred to the ED for evaluation from a psychiatric hospital on 3/9/2022 after an unwitnessed fall at an acute psychiatric hospital. The patient was admitted to the psychiatric hospital on 3/4/2023 for agitation. Patient ID # 1 has a history of developmental delay, dehydration, and syncope. Upon arrival the patient was tachycardic with a heart rate of 138, a Computerized Tomography (CT) scan of the head was normal, and CT of chest demonstrated a small left lower lobe pulmonary embolism (PE). The patient was started on IV fluid due to dehydration and Eliquis for the PE and admitted for further evaluation and management. The record reveals that on 3/9/2023 at 3:21 a nurses note states, "integumentary assessment skin warm/dry, bruise to forehead".
In addition, the record reveals that the patient has self-injurious behaviors which includes biting. Additionally, during his/her hospital stay the patient was placed in soft upper and lower restraints for prevention of self-harm and had a staff sitter. The record reveals that the patient remained in the ED from 3/9/2023 through 3/21/2023 and was transferred to the 3 South unit on 3/21/2023.

Review of the record lacked evidence that an initial skin assessment was completed on 3/9/2023. The record lacked skin assessments were completed on 3/10/2023 or upon discharge on 3/21/2023. Additionally, the record lacked documentation of bruises other than on the upper and lower extremities and hands.

Review of the findings filed to the state agency by the psychiatric hospital, of the re-admission skin assessment finding and photos of the patients skin revealed the patient had multiple bruises, including a bruise on the left upper forehead at hairline with swelling, right upper parietal region bruises with swelling, reddened area on crown of head, left forearm clear handprint (fingers easily visible), and left and right upper arm bruises. Additionally, the right hand first knuckle index finger had a bite wound, left hand first knuckle index finger also bite wound, the right knee was reddened, a left shin bruise, right mid axillary bruise at fifth rib, a reddened sacrum, which is blanchable, skin abrasions on right and left upper buttocks, right and left thigh bruise.

During an interview on 3/21/2023 with Staff A, the staff nurse who was assigned to the patient when she transferred from the emergency department to 3 South unit and had also discharged the patient to the psychiatric hospital later 3/21/2023, she informed the surveyor that she only had the patient a short time when the call came that a psychiatric bed was available. When asked about his/her skin and the multiple bruises, she stated that she had not completed a skin assessment when the patient was transferred to his/her care from the emergency department. She stated the patient was in soft restraints upper and lower extremities and that he/she was banging her/her head on the side rails, so she padded the rails. She stated that the emergency room only provides the name of the patient, and the report is in the computer and the nurse needs to review it. She acknowledged that she did not review the information about the patient. She stated the emergency department staff nurse who had been caring for the patient is the one who called the report to the psychiatric hospital. She stated she was not aware of the condition of the patient's skin.

During an interview with the Risk Manager on 3/30/2023 at approximately 10:15 AM, she was unable to produce evidence that the initial skin assessment with a two nurse sign off was completed per the hospital policy, that daily skin assessments were completed on 3/10/2023 or 3/21/2023 per the hospital policy, or that a skin assessment with a two nurse sign off was completed prior to the patients transfer to the inpatient unit on 3/21/2023.

2. Review of the record for Patient ID # 4, revealed he/she was admitted to the hospital on 10/20/2022 from an acute psychiatric hospital after testing positive for Covid for further medical management quarantine and medical clearance prior to return. Review of record reveals that the initial skin assessment dated 10/20/2022 was not completed per the hospitals policy.

During an interview with the Risk Manager on 3/30/2023 at approximately 9:40 AM, she was unable to produce evidence that the initial skin assessment had been completed per policy and acknowledged that the Braden scale and full body assessments were not completed upon admission.

3. Review of the record for Patient ID # 7, revealed that he/she was admitted to the hospital on 3/24/2023, after presenting in the emergency department four days post laparoscopic cholecystectomy for severe right upper quadrant abdominal pain and tenderness. The patient was admitted for evaluation of pain and to rule out bowel injury or bile leak. Review of record reveals that the initial skin assessment dated 3/24/2023 was not completed per hospital policy.

During an interview with the Risk Manager on 3/30/2023 at approximately 9:55 AM, she was unable to produce evidence that the initial skin assessment was complete, or two nurses had signed off on the initial skin assessment as required by hospital policy.

Based on record review and staff interview it was determined that the hospital failed to keep a current nursing care plan which meet the needs of the patient for 1 of 1 patient, Patient ID #1, relative to assessments, reassessment, and discharge documentation relative to skin assessments.

Findings are as follows:

Review of the hospital policy reveals, "Patient Assessment, Reassessment, and Discharge Documentation" dated 10/9/2020 states in part:

Purpose: The purpose of this Patient Assessment, Reassessment and Discharge Documentation policy is to outline standards for assessing patient care needs and guidelines for the documentation of patient status, progress, and care.

Policy: It is the policy of Kent Hospital that all patients assigned a status of inpatient, or observation will be assessed by an RN/LPN according to the following guidelines. The RN/LPN may delegate elements of assessment and reassessment to a Nurse Assistant that do not require assessment, evaluation, or analysis such as vital signs, height, and weight.

...Procedures:
Inpatient Assessments
A. Initial assessments of inpatients must address the following and shall be completed with twenty-four hours of the patient's admission order:
~Braden scale and a full body skin assessment
B. If an assessment cannot be completed within this time frame, documentation shall reflect the reason.
2. Reassessment of Inpatients
a. Patient care needs shall be reassessed at a minimum with each change in RN caregiver typically associated with shift change.
C. Interdisciplinary Plan of Care
1. An individualized plan of nursing care shall be developed by the Registered Nurse. It shall reflect current nursing standards, shall be consistent with the medical plan and shall promote patient's well-being and knowledge or self-care. This plan shall include:
~ Problem Identification
~ Realistic goals mutually set with the patient/family.
~Interventions/Patient Family Teaching
E. Discharging a patient.
2. The RN shall complete the Continuity of Care Form."

Record review for patient ID # 1, reveals h/she is developmentally delayed. H/she arrived at the ED on 3/9/2023 for evaluation after an unwitnessed fall. The patient was tachycardic with a heart rate of 138, a CAT scan (CT) of the head was normal, and CT of chest demonstrated a small left lower lobe pulmonary embolism (PE) and the patient was started on intravenous (IV) fluids due to dehydration and also started on Eliquis (a blood thinner) for the pulmonary embolism.

Review of a nursing note dated 3/9/2023 states, "integumentary assessment skin warm/dry, bruise to forehead".
Record review lacked evidence that the initial skin assessment on 3/9/2023 was completed. The record lacked skin assessments had been completed on 3/10/2023 or 3/21/2023 prior to transfer to another unit per the hospitals policy. Additionally, the record lacked any documentation of bruises other than on the upper and lower extremities and hands.

During an interview with Staff D, emergency department Charge Nurse on 3/29/2023 at approximately 1:15 PM, relative to completion of skin assessments and documentation, she informed the surveyor that the "she was not sure how often the full body assessments should be completed but once a shift". Additionally, she stated that if the skin assessments were not completed there should be a note in the record stating the reason they were not completed.

During an interview with Staff E, float nurse in the emergency department on 3/29/2023 at 12:15 PM, she informed the surveyor that she only cared for patient ID # 1 once for three and a half hours and that she did not look at the patient's skin and was unsure if the patient had any bruises.

During an interview with Staff C, an emergency department staff nurse on 3/30/3023 at approximately 10:30 AM, she informed the surveyor that she took care of the patient on several occasions. She informed the surveyor that the patient's mother stayed with the patient most of the time, and that the patient was behavioral and would bang h/her head and legs on the side rails. She stated that the patient had been place in upper and lower soft restraints for her protection making it difficult to assess her skin. She also stated that the patient had a long sleeve pajamas (PJ) that she liked to wear, therefore could not always assess her skin. She stated that she was unsure of the status of the patient's skin, and documented the bruises that she saw, and acknowledged if the record did not state why the assessments were not completed then she did not document them.

Review of the Continuity of Care Plan that was sent to the receiving psychiatric hospital on 3/21/2023, this document lacked evidence of any information in the problem list relative to the patient's skin and or the patient behaviors.

Documentation on the problem list section of the form list Developmental delay & Osteoporosis. The form fails to include any information relative to the patient's skin condition.

During an interview with Staff A, on 3/29/2023 at approximately 2:15 PM, the nurse who discharged the patient to the psychiatric hospital on 3/21/2023, she informed the surveyor that she only had the patient a short time when the call came that a psychiatric bed was available. When asked about her skin and the multiple bruises, she stated that she had not completed a skin assessment prior to the patient being discharged and acknowledged that she had not reviewed the documentation which described the patient. The ED staff nurse who had been caring for the patient called the report to the psychiatric hospital. She stated she was not aware of the condition of the patient's skin. She stated that the continuity of care form was completed by others and that she only wrote the "Nursing Progress Summary" which did not contain any information relative to the patient's skin condition.

During an interview with the Risk Manager on 3/30/2023 at approximately 10:15 AM, and she was unable to produce evidence that the hospitals policy "Patient Assessment, Reassessment, and Discharge Documentation" was followed. She acknowledged that the record lacked documentation for skin assessments as required by hospital policy. Additionally, she was unable to produce evidence that the plan of care/continuity of care form was complete as evidenced by the limited problem list and lack of any documentation describing the multiple bruises and skin condition prior to the patient being discharge on 3/21/2023.