HospitalInspections.org

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that hospital staff members systematically reassessed patients to 1) determine if they were at risk for skin breakdown; and 2) determine if the skin condition of patients with actual or potential skin breakdown was improving or deteriorating, as demonstrated by 3 of 5 patients reviewed (Patient #1, #2, #3).

Failure to assess a patient's risk for skin breakdown and to provide nursing interventions according to the results of that risk assessment risks elderly and immobile patients developing pressure ulcers.

Findings included:

ITEM #1 - SKIN BREAKDOWN RISK ASSESSMENTS

1. Review of the hospital's policy and procedure titled "Skilled Swing Patient Assessment Reviews", Policy #14.3.018 reviewed 07/09/18, showed that long-term care patients would be assessed quarterly for risk of skin breakdown using the Braden Scale, an assessment tool that predicts the risk of pressure ulcers based on sensory perception, moisture, activity, nutrition, and friction and shear.

2. On 04/24/19 at 8:55 AM during an interview with Investigator #1, the hospital's long-term care coordinator (Staff #1) stated that the quarterly patient assessment did not include assessment of the patient's risk for skin breakdown. The staff member stated that patients were assessed for risk of skin breakdown using the Braden scale only on admission


ITEM #2 - SKIN ASSESSMENTS

1. On 04/24/19 at 12:50 PM, Investigators #1 and #2 requested copies of portions of the medical records for Patients #1, #2, and #3. Review of these records showed the following:

a. Patient #1 was a 70 year-old patient who had been admitted to the hospital for long-term care services on 07/01/17. On 01/21/19, the patient was diagnosed with a left ankle fracture and was placed in a posterior short-leg splint (a splint that covers the back of the leg and heel) wrapped with an elastic bandage. On 01/24/19, the splint was removed and replaced with another padded splint. There was no documentation in the patient's record between 01/24/19 and 01/28/19 indicating that hospital nursing staff assessed the patient's skin to determine if the splint was fitting correctly.

b. Patient #2 was a 79 year-old patient who had been admitted to the hospital for long-term care services on 02/25/18. The patient was non-ambulatory and spent his waking hours in a wheelchair. On 02/14/19 and 02/18/19, nurses notes indicated that the patient had skin breakdown in his buttocks area. There was no documentation of assessments of the patient's skin by hospital nursing staff between 02/18/19 and 4/24/19 to determine if the skin had healed.

c. Patient #3 was a 96 year-old patient who had been admitted to the hospital on 07/01/17 for long-term care on 07/01/17. Review of nursing notes dated 12/20/18 and 12/24/18 showed that the skin on the patient's buttocks was reddened and excoriated. Skin breakdown was also noted on 01/21/19, 02/25/19, and 04/09/19. There was no documentation of assessments of the patient's skin by hospital nursing staff members between 12/24/18 and 1/21/19, 01/21/19 and 02/25/19, 02/25/19 and 04/09/19, and 04/09/19 and 04/19/19. On 04/19/19, nursing documentation showed the patient's skin condition had deteriorated and daily skin assessments were needed.

2. During an interview at the time of the record review, the hospital's long-term care coordinator (Staff #1) and Chief Nursing Officer (Staff #2) confirmed that the hospital's nursing staff did not have a systematic process for performing and documenting assessments of the patient's skin condition.
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