HospitalInspections.org

The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.

This STANDARD is not met as evidenced by:
Based on interview and record review, patient care staff failed to include a problem statement in the nursing care plan for prevention of skin breakdown.

Findings:
Review of medical record #1 identified the following deficiency regarding the failure to include a problem statement for prevention of skin breakdown:

1. The patient was a 57 year old male who was developmentally delayed. He presented to the Emergency Department (ED) on 10/7/2019 at 10:15 am due to volume overload in the setting of End Stage Renal Disease. The patient was admitted in a debilitated state and complaining of pain. His admission Braden Scale (assessment tool for determining risk for skin breakdown) was 13 (high risk for acquiring a skin injury). Patient also had a history of sacral pressure ulcers.

2. The admitting nurse documented the patient's sacral area was reddened and applied a silicone dressing to the area on 10/7/2019 at 9:50 pm.

3. Upon developing the nursing care plan on 10/7/2019 at 10:18 am in the ED, nursing staff failed to include a problem statement for the prevention of skin breakdown. Nursing revised the nursing care plan on 10/9/2019 at 9:42 am and again failed to include a problem statement for the prevention of skin breakdown.

4. Record review and interview of Staff #A indicated Nursing was providing skin care and skin breakdown prevention per hospital's policies and procedures:
- Skin Assessment, Pressure Injury Prevention and Documentation/Treatment.

Interview of Staff #A conducted on 11/30/2020 at approximately 11:00 am verified that a problem statement for the prevention of skin breakdown was not present in the medical record of patient #1.