HospitalInspections.org

Based on document reviews and interviews, nursing staff failed to perform a skin assessment on an immobile patient who presented to the facility's emergency department with wounds in 1 of 2 records reviewed (Patient #3) for patients who presented to the offsite campus emergency department (ED).

Findings include:

References:

According to the Lippincott Procedures-Pressure Injury Prevention reference, a Stage 2 pressure injury is characterized by partial-thickness loss of skin with exposed dermis (the thickest layer of the skin made up of fibrous and elastic tissue). Most pressure injuries develop over bony prominence's, where friction and shearing force combine with pressure to break down the skin and underlying tissues. Common sites include the sacrum (bony structure that is located at the base of the lower spinal column) and scapulae (shoulder blade)

1. Emergency department nursing staff failed to perform a skin assessment on an immobile patient who presented with wounds upon admission to the hospital.

a. Review of Patient #3's medical record revealed the patient presented to the facility's offsite campus emergency department for an evaluation of fever and elevated blood sugars at 8:47 a.m. on 12/30/18. Patient #3 remained in the ED until 4:26 p.m. Review of the admission History and Physical, dated 12/30/18 at 4:06 p.m., showed Patient #3's range of motion was limited by generalized weakness, deconditioning and chronic changes related to cerebral palsy (congenital disorder of movement, muscle tone, or posture).

On 12/30/18 at 9:00 p.m., the patient's inpatient admitting registered nurse (RN #4) documented Patient #3 had a pressure injury wound to her right scapula and another wound located at her coccyx (bony structure at the bottom of the spine). RN #4 documented both wounds were present on admission to the hospital unit. A wound care consult was ordered on 12/31/18 at 2:03 a.m.

On 12/31/18 at 8:27 a.m., the wound care nurse (RN #3) documented Patient #3 had a purple 3 x 2 centimeter area to the coccyx and a smaller open Stage 2 wound with purple margins to the right scapula area. RN #3 noted the evaluation was completed due to the patient's limited mobility.

There was no evidence in Patient #3's ED documentation which showed the patient's wounds, which were identified upon admission to the inpatient unit, were assessed during the patient's eight hour ED stay.

b. On 4/24/19 at 2:39 p.m., an interview was conducted with RN #3. She stated pressure injuries usually started with prolonged resting at bony prominence. She said tissue death occurred from the prolonged pressure at the site.

RN #3 stated she remembered Patient #3. She said the patient had a deep tissue injury to her coccyx. RN #3 reported the patient was completely immobile and did not turn herself. RN #3 stated the patient's wounds were present when the patient was admitted to the hospital. She said wounds needed to be identified within the first 24 hours of a patient's admission.

c. On 4/24/19 at 3:23 p.m., an interview was conducted with ED RN #2, the nurse who was responsible for Patient #3's care on 12/30/18. RN #2 stated he was charge nurse 90% of his shifts. RN #2 stated nursing staff charted in medical records by exception. He said nurses conducted a brief skin assessment when patients came into the ED if there was a skin concern.

RN #2 reviewed Patient #3's ED record. When asked if the patient's skin was intact, he stated he did not remember the patient. RN #2 was unable to find a nursing skin assessment in the ED record documentation. He said if it was not documented, he did not know if it happened or not.

d. On 4/23/19 at 8:00 a.m., an interview was conducted with another ED nurse (RN #6). He stated, depending on the patient's complaint, he conducted a skin assessment when the patient undressed. However, RN #6 stated if a patient was incapacitated he would look at pressure points, including elbows and the sacrum area.

e. On 4/24/19 at 3:53 p.m., an interview was conducted with the chief of staff (ED Physician #1) who provided care during Patient #3's ED stay on 12/31/18.

Review of his ED note, dated 12/30/18 at 9:00 a.m., showed no documentation about Patient #3's wounds, which were present on admission to the hospital. He said the process for skin assessments in the ED was to get the patient undressed and perform an exam. He said, the majority of the time, the ED staff would be worried about cardiopulmonary immediate life threats and trauma. Physician #1 stated it was hard to catch everything if skin issues were not obvious. He said if there was a life threatening situation, the skin assessment would be delayed. Physician #1 stated he relied on nursing staff to help physicians with patient skin assessments and notify them when there was a concern.

Physician #1 stated he remembered Patient #3. Physician #1 reported normally his normal process would be to document a Stage 2 wound but he could have forgot.

f. On 4/25/19 at 9:12 a.m., an interview was conducted with the regional clinical nurse specialist (Specialist #5) for the emergency departments. She stated in the ED, focus assessments were done based on the patient's initial complaints. She said if the patient came in the ED with skin related complaints, a skin assessment would be documented. Then she said if the patient's complaint was not a skin concern, there would not be any documentation in the medical record. Specialist #5 stated recently, there was a patient at the offsite campus ED who was bedbound and the chart was reviewed. She said the facility found a disconnect with charting in the ED record. Specialist #5 confirmed it was Patient #3.

g. Review of emails provided by the facility regarding Patient #3, dated 3/15/19, revealed the facility had discussions about ED skin assessments and were in the process of researching ED specific skin assessment tools which could be used by nursing staff. Upon exit, the facility could not provide evidence any ED skin assessment tools had been implemented.