HospitalInspections.org

Based upon interview and record review, the facility failed to ensure that care plans were updated with patient's current (skin) problems in 2 out of 10 sampled patients (SP) SP#1 and SP#2.

The findings include:


1. Review of SP#1 closed medical records on 07/07/14 & 07/08/14 showed that the patient was admitted to the facility on 04/14/14 for fall with injuries to left hip and left knee. Review of Nursing Admission of 04/14/14 at 23:55 pm showed was assessed to be at high risk for skin breakdown and based on this assessment, interventions included turning every 2 hours. The Wound Care Protocol Order on 04/15/14 at 06:30 am showed that the patient had a stage 2 pressure ulcer to the buttocks. Photographic wound documentation on 04/15/14 also show that the patient has a stage 2 decubitus, on the sacrum, that was present upon admission.
Further review of the Photographic Wound Documentation dated 04/15/2014 revealed that there is a stage II sacrum wound x2. Review of the Photographic Wound Documentation dated 04/23/2014 revealed that the sacrum wound had deep tissue injury and had increased in lenth, width. On 05/02/2014 the Photographic Wound Documentation revealed that the wound had increased in size and was unstageable.

Review of the patient ' s Care Plan from 04/14/14 to 05/16/14 did not show that the patient ' s impaired skin integrity was included as one of the problems.

2. Review of SP#2 closed medical records on 07/07/14 & 07/08/14 show that the patient was admitted to the facility on 05/02/14 for fracture of left femur. Photographic Wound Documentation on 05/02/14 showed that the patient had a scar from a healed ulcer on the sacral area. Review of the Photographic Wound Documentation on 05/14/14 showed that the patient had a stage II pressure ulcer to the sacrum. Nursing Assessments from 05/14/14 to 05/16/14 also showed that the patient had a stage II pressure ulcer to the sacrum.

Review of the patient ' s Care Plan did not show that skin integrity was addressed as one of the patient 's problems.


In an interview with the Director of Nursing Practice on 07/08/14 at 3:30 pm, she stated, " care plans are updated as needed to include all of the patients' concerns.