HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that nursing care in the form of skin assessments on each shift were performed for 1 of 3 sampled patients (#1).

Findings:


A review of the medical record of patient #1 was performed. The patient presented to the Emergency Room on 1/02/10 and was admitted to the hospital proper later that day.

A review of facility policy "Wounds - Risk and Assessment" revealed the following: "All patients . . . admitted to Health Central will have a skin integrity assessment within four hours of admission . . . . Thereafter, the patient will have a skin surface assessment by an RN or LPN every shift. Assessments will be documented on the Nursing CRV under the Skin/Ulcer class."

A nurse's note on 2/17/10 at 8:19 AM mentioned that Mepilex dressings were in place at the locations of the right buttock and left hip. This was the first mention in the medical record of any skin issues at these locations. A nurse's note on 2/17/10 at 10:40 AM had the first descriptions in the medical record of these two wounds. They were described as: "2 necrotic areas and 1 reddened excoriation area near scrotum - all cleansed with wound cleanser and Mepilex changed." Nurse's notes of 2/19/10 at 7:30 PM read: "Unstageable pressure sore R ankle = medial, scab." This was the first mention of this wound in the medical record. Wounds discovered with the descriptions indicating necrosis and/or being unstageable as shown above are indicative of something of long duration; at least more than one day. There is no way to prove that these wound sites had been assessed each shift, as per facility expectations, prior to their first documented mentions. If the sites of necrosis had been properly assessed on a number of shifts prior to their first mention, discrepancies in some form would have been noticed. As such, their documentation would have been mandated.

During an interview with the assistant unit manager on 3/04/10 at approximately 4:07 PM, she confirmed the above findings from the medical record. She confirmed the facility policy requiring skin assessments on each shift.