HospitalInspections.org

Based in a review of documentation and interview, the facility failed to ensure the right to receive care in a safe setting, by not performing skin assessments at the frequency indicated in facility policy.

Findings included:

Facility based policy entitled, "Pressure Injury Prevention" stated in part,

"PURPOSE:
Outline expectations for risk assessment, physical assessment, application of interventions, and
documentation for the prevention of pressure injuries.

TOOLS:
Adult patients 2: 18 years of age will be assessed using the Braden II scale
o AT RISK= score ? 18
o NOT AT RISK = score > 18 ...

PROCEDURE STATEMENTS:
1. Skin risk assessment will be documented in the Electronic Health Record (EHR) for each patient.
2. Ongoing, skin assessments will be as follows:
a. For patients determined NOT to be at risk (per risk scale), skin assessments are completed with daily, comprehensive patient assessments.
b. For patients determined to be AT RISK (per risk scale), skin assessments are completed at a minimum of twice per shift, or at a prescribed cadence as ordered by a licensed practitioner.
3. Skin assessment changes and presence of any skin alterations or wounds will be documented in the EHR for all patients.
a. Skin alteration documentation should include the following, as applicable:
1. Skin alteration location and type;"

Review of medical records revealed the following:

3 of 5 patients were high risk for pressure injury per their Braden scale scores and did not have skin assessment completed twice per shift per facility policy.
* Patient #1 had an initial Braden Scale score of 11 on 06/28/24, placing them at high risk for pressure injury. From 06/28/24 through 08/22/24, skin assessments were only performed on this patient once, not twice per shift per facility policy. Patient #1 had pressure injury develop while inpatient.
* Patient #6 had an initial Braden Scale score of 12, placing them at high risk for pressure injury. On 10/01/24 their Braden score increased to 19, placing them not at risk. From 09/29/24 - 09/30/24 skin assessments were only performed on this patient once, not twice per shift per facility policy.
* Patient #8 had an initial Braden Scale score of 11, placing them at high risk for pressure injury. From 09/30/24 - 10/01/24 skin assessments were only performed on this patient once, not twice per shift per facility policy.

Staff members #1 and 2 verified that the above high risk patients for developing pressure injury did not have skin assessments completed at a minimum of twice per shift, per facility policy.