HospitalInspections.org

Based on interview and record review the facility failed to provide nursing services in an organized manner when the nursing staffs did not fully and consistently assess patient #7's skin.

Findings include:

Review of Patient #7's skin assessment dated 5/31/19 at 3:00 am reflected, " ... left ear scab, sacrum, dressing intact." Previous documentation did not indicate a wound to the left ear or sacrum wound. There were no measurements or descriptions of the wounds. Further documentation on 5/31/19 at 7:55 am, of the sacrum, reflected, " ... skin intact and dressing clean dry intact, unable to assess due to dressing." Patient #7 was discharged on 6/5/19 the medical records did not reflect the changing of the dressing or the reason for the dressing, recording whether the skin was broken or it was being used as a preventative measure.

During an interview on the afternoon of 7/16/19, Staff #6, ICU Charge Nurse stated, " ... We sometimes put a happy hinny (Aquacel Adhesive Foam Barrier) on a patient's sacrum if we think they are at risk of getting a wound." When asked how they check to see if there is any new skin breakdown under the dressing Staff #6 stated, "We can pull it back and check it. The dressing gets changed every three days ...."

Review of the facility provided policy WOUND CARE (dated 9/12) reflected, "Each patient admitted will have a skin assessment by an RN and documentation in the EMR of any skin redness or breakdown ... If skin is intact without moisture, us a barrier product to protect the skin, such as duoderm ... Step 2 Measure the wound with the wound measuring guide .... Document should be performed in iView under lines/wound/devices tab and should include:
o wound type and size ...
o appearance of wound bed
o appearance of per-wound area
o wound care provided

During an interview on the afternoon of 7/16/19 Louise Watkins, Risk Manager confirmed the findings and stated, " ...each shift there should be a full head to toe assessment ..."