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Based on medical record review, interviews, and policy and procedure review, the hospital failed to develop a plan of care that addressed actual, or the potential for changes in Patient Identifier (PI) # 1's skin.
On admission 2/7/11, PI # 1 was identified to be at high risk for alteration in skin integrity based on the nursing assessment of "fragile skin," requiring assistance with transfers and activities of daily living, use of Plavix (anticoagulant medication), cognitive function and age. According to a body audit (dated 2/7/11), PI # 1 had a two small bruises and abdominal "surgical scars."
On 2/28/11, a body audit documents that PI # 1 was found to have multiple bruises of unknown origin that were not identified on the admission nursing assessment.
This deficient practice affected PI # 1, one of ten sampled residents.

Findings Include:

Medical Record Review:
History and Physical (2/8/11): PI # 1, an 83 year old patient with a history of Dementia, was admitted to the hospital from a nursing home due to agitation with aggression and decreased sleep on 2/7/11.

According to the Physician Orders, dated 2/7/11, Plavix 75 milligrams daily was ordered prior to admission and was to be continued in the hospital.

The Nursing Admission Assessment, dated 2/7/11, identified PI # 1 as having "thin skin," a small bruise to the right forearm, a small bruise to the left hand and abdominal surgical scars. PI # 1 was alert and oriented to person only.

A body audit dated, 2/21/11, documents redness and swelling to the patient's right foot. No bruising is documented.

A Nursing Progress Note (by Employee Number [EI] # 2 / Staff Registered Nurse [RN]) on 2/28/11 at 10:00 PM, revealed bruises, in differing stages of healing, "all over" PI # 1's body. The nurse noted the bruises were found when PI # 1 was being given a shower.

A review of PI # 1's Master Treatment Plan revealed there is no care plan identified regarding PI # 1's skin issues.

During an interview on 3/23/11 at 9:30 AM, the Program Manager / Employee Identifier (EI) # 1 was asked about the policy for body audits. EI # 1 stated audits are to be done on admission and every seven days.

On 3/24/11 at 3:30 PM, the Program Manager / EI # 1, provided a policy, "Physical Assessment, revised 12/09. A review of the policy revealed:
"1. The initial assessment is to be performed within four hours on each patient admitted to the hospital....
3. The Registered Nurse (RN) determines any immediate needs, performs the initial physical assessment, and makes the final determinations, conclusions, and prioritization of patient needs and/or nursing diagnosis to be used as the basis of the plan of care..."

During an interview on 3/29/11 at 9:30 AM with Staff RN / EI # 2, the RN stated she was called to the shower room on 2/28/11 by a Mental Health Technician (EI # 9, not available for interview) who was bathing PI # 1.
EI # 2 stated she found multiple bruises all over PI # 1's body, and according to EI # 2, there had been no report of PI # 1 falling.
EI # 2 documented the size, color and location of the bruises in the Progress Notes dated 2/28/11. EI # 2 reported she informed the next shift about the bruising as well as EI # 1, the Program Manager.

Policy and Procedure: Multidisciplinary Treatment Planning
Issue Date: 7/01 Revised: 9/08 includes:
I. "Purpose: 1. To provide individualized care responsive to patient specific needs...
II. Policy: A. Each patient shall have a written individualized treatment plan based on the patient's presenting problems, physical health, emotional and behavioral status...This includes a review of the data available at the time of the formulation of the plan to include:
1. Psychiatric Assessment...
4. Nursing Admission Assessment...
III. Procedure:
A. The Registered Nurse responsible for the admission of the patient shall initiate the Multidisciplinary Problem list, based on the initial Nursing Assessment. Medical problems requiring active treatment during the admission will be
identified..."

This citation is written as a result of the investigation of Complaint Number AL00024016.