HospitalInspections.org

Based on interviews and documentation review, the registered nurses (RN) failed to evaluate skin integrity on a continuum, by establishing a comprehensive baseline and then performing daily by utilizing prior assessments for comparisons to determine the patient's skin current status. This occurred in six or six patients (Patients # 1, 2, 3, 4, 10, and 16) on the mental units.

Findings:

On 03/13/17, the hospital policy titled, "Admission Nursing Assessments-General and Special Assessments 8/14" was reviewed. The policy documented a general nursing assessment should be initiated as soon as possible upon arrival to the unit and completed within twelve hours.

On 03/13/17, the hospital policy titled, "Interdisciplinary Comprehensive Patient Assessment 9/14" was reviewed. The policy documented the purpose of the assessment, which included a skin assessment, was to determine the need for treatment, care, and services and to develop a treatment plan.

On 03/14/17, Staff G stated the skin assessments were performed by the registered nurse at the patient's admission and twice a shift thereafter. Staff G stated the skin assessments were documented in a flow chart in the electronic medical record.

On 03/14/17, the EPIC flow chart for skin assessment reviewed. The system had drop down windows with adjective descriptions that the staff would select. The system also allowed for comments to be added. Upon review of the seven patients' medical records, the comment section, which afforded staff greater descriptors of skin integrity, in narrative form, was only used two times on one patient record.

On 03/14/17, seven medical records were reviewed from patients of various units. Inconsistent descriptions of skin documentation was seen in seven of seven patients (Patients # 1, 2, 3, 4, 5, 10, and 16) on the mental units. The following are illustrations of progressive inconsistent descriptions of skin integrity within a patient's medical record.

Patient #1:
Within a ten day period , the patient's skin integrity was randomly described as "bruising,ecchymosis", sometimes with "bilateral upper extremities", sometimes included the "abdomen", sometimes described as "purple multiple bilateral upper extremities", sometimes "bruising,ecchymosis hand and arms".

Patient #2:
Within an eleven day period, the patient's skin integrity was randomly described as "warm/dry, excoriations/ scratches" , sometimes "abrasion" was added to the description, sometimes "abrasions only", sometimes "excoriations/ scratches" with no site was specified.

Patient #3:
Within a five day period, the patient's skin integrity was randomly described as "bruising/ecchymosis" with comment,and sometimes "warm/dry" only.

Patient #4:
Within a ninety-nine day period, the patient's skin integrity was randomly described as "excoriated/scratches" with no specified site, sometimes "excoriated/scratches- abdomen or stomach", and sometimes "excoriated/scratches- face and bilateral arms".

Patient #5:
Within a fifty-eight day period, the patient's skin integrity was randomly described as "Warm/dry", and sometimes "excoriated/scratches" with no site specified, and sometimes "excoriated/scratches forearms",

Patient #10:
Within an eleven day period, the patient's skin integrity was randomly described as, "Abrasion, bruising, ecchymosis- R buttock fading", and sometimes "Abrasion, bruising, ecchymosis" with no specified site, sometimes, "Abrasion, bruising, ecchymosis- L arm, R buttock- fading purple multiple", sometimes "Abrasion, bruising, ecchymosis- excoriations/scratches- bilateral upper extremities- fading purple multiple", sometimes "Abrasion, bruising, ecchymosis- tear-head clean/dry & ecchymosis-steri strips", and "Abrasion, bruising, ecchymosis-tear".

Patient #16:
Within a four day period, the patient's skin integrity was randomly described as "warm/dry- bruising ecchymosis general multiple, Coccyx -clean dry, closed wound edges", sometimes no description of bruising, "Left side of face- left eye blue/green", and sometimes "bruising/ecchymosis".

This failure resulted in incomplete skin assessments of all compromised areas. The lack of description hindered the hospital's ability to determine when a compromised area occurred and whether the area improved or worsened. The failure to thoroughly document baseline skin assessments hindered the ability to determine if a patient had compromised skin prior to admission or if compromised areas occurred during the hospitalization.