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Based on complaint review, record review, staff interview, and policy review, the facility failed to ensure Patient #1's skin integrity was assessed on an ongoing basis during her hopital stay.


Findings include:


The State Office received a complaint from Patient #1's daughter regarding the patient's skin condition on discharge from the hospital after a 13 day admission to their Geriatric Psychiatric (Geri-Psych) Unit. She stated that on admission her mother had no skin breakdown, bruises or scratches. When she was discharged home her left leg was scratched and bleeding, her buttocks were red and blistered, and her right great toe was bleeding and had a bruise type mark, there was a bluish bruise on her right chest, a bruise on her right arm above her wrist, and a bruise on her left arm above the elbow.


The facility was entered on 4/14/16 at 8:00 a.m. Review of the facility's complaint log revealed that Patient #1's daughter had made a complaint to the hospital regarding her mother's care during her stay and her condition on discharge. During an interview with the Chief Nursing officer at 8:45 a.m. she revealed that she was aware of the complaint.


Record review revealed that Patient #1, a 90 year old female, was admitted to the hospital's Geri-Psych Unit from home on 3/11/16 with delusional behavior, confusion, aggressive behavior, not eating, sleep disturbance and visual/auditory hallucinations. She had a past history of Hypertension, COPD, CAD, dementia and possible CHF. The patient's admission assessment showed her skin on admission was WNL (within normal limits) with no documented evidence of any scratching, bruising or breakdown. One admission assessment documented a Braden Scale of 16, another for the same day documented a Braden Scale of 18. (The Braden Scale is used to assess the patient ' s level of risk for development of pressure ulcers and is based on sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The total scores range from 6-23. A lower Braden Scale Score indicates a lower level of functioning and, therefore, a higher level of risk for pressure ulcer development. A score of 19 or higher would indicate that the patient is at low risk). The assessment showed Patient #1 required total assitance with ADLs (activities of daily living).


Review of the facility's "Nursing Service Skin Assessment Protocol" dated 9/27/14 revealed: "... Purpose: To provide each patient with a skin assessment on admission, throughout hospitalization, and at discharge. Policy: Maintain procedures to ensure that staff properly assesses each patient for skin breakdown.... Procedure: ...3. If the patient has any kind of skin breakdown or is high risk, meaning Braden scale is 16 or less, the nurses will implement the skin assessment decision tree..."


Review of the facility's "Skin Assessment Decision Tree" dated 9/27/14 revealed: "... High risk 1) Braden scale less or equal to 16. 2) Turn every 2 hours..."


Review of aide documentation for Patient #1 during her hospital admission revealed no aide documentation for 3/13/16 or for 3/17/16, and no documentation of the aide turning the patient every two (2) hours on 3/11/16, 3/12/16, 3/14/16, 3/15/16, 3/16/16, and 3/18/16 thru 3/24/16.

Interview on 4/14/16 at 11:10 a.m. with the Chief Nursing Officer revealed, "I am unable to find any aide notes for March 13 and March 17, 2016" At 12:10 p.m. the Chief Nursing Officer stated, "I could not find any documentation on aides turning the patient every two hours."


There was no documented evidence that facility nursing staff completed a skin assessment decision tree during her hospital stay. Review of the patient's 3/24/16 11:00 a.m. Discharge Assessment revealed no documented evidence that a skin assessment was completed at discharge.

No further documented evidnce was submitted by hospital staff during Exit Conference.