HospitalInspections.org

Based on staff interview and document review, it was determined the facility failed to ensure all licensed nurses adhered to hospital policies and procedures. Specifically, nursing staff failed to follow hospital policy related to conducting a head-to-toe assessment to include a skin assessment in one (1) of nine (9) medical records reviewed in the survey sample. Patient #3 (P3).

Findings:

A review of the facility's policy, "Acute Care Services Level of Care Policy" (10/2024) reads in part, "...Nursing Assessment: A full head-to-toe assessment will be charted at various intervals during a 12-hour nursing shift based off the level of care...General care - full assessment documented every twelve hours (recommended at 8 AM and 8 PM). More focused assessments can be completed as needed."

The facility's policy, "Pressure Injury and Prevention and Treatment Guidelines for Adults and Pediatrics 8 Years and Older" last revised May 2022 was reviewed and reads in part, "...Assessment Procedure...skin assessments should be completed at change of shift utilizing the Braden Scale Assessment. Documentation of each assessment should include the following: 1, Integumentary flow sheet assessment. 2. Braden scale flowsheet assessment 1. Include all current preventative measures and interventions in place. 2. Include the current bed type under the patient..."

P3's medical record contained documentation that two (2) nurses performed a skin assessment that revealed redness to bilateral heels and sacrum upon admission. A nursing care plan was initiated for the patient on December 24, 2024 at 1:44 AM that included "Potential for compromised skin integrity." The following interventions were documented, "Every shift - monitor for areas of redness/skin breakdown; turn and reposition every two hours; suspend heels using pillow or device; implement toileting schedule; encourage mobility as appropriate; limit linen layers; utilize external urinary containment device; skin care to include moisturizers and protective dressings; utilize moisture management pad; promote and monitor adequate nutrition intake.""

P3 was noted to have developed a left heel deep pressure injury and stage one pressure injury to the right heel and sacrum on December 31, 2024. The medical record for P3 failed to contain a head-to-toe shift assessment to include a skin assessment from the 07:00 AM to 7:00 PM shift on December 30, 2024.

An interview was conducted with EMP4 (employee) during record review on April 16, 2025 at approximately 1:00 PM. EMP4 confirmed that a full head-to-toe assessment should be completed each nursing shift and P3's medical record failed to contain a nursing shift assessment on December 30, 2024 from 7:00 AM to 7:00 PM.