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Based on interview and record review, the facility failed to ensure that a registered nurses (RN) supervised and evaluated the nursing care for 5 of 8 sampled patients (Patient ID # 1, 2, 3, 4, 8 ).

Review of patient skin assessments performed by nursing staff showed several assessments to be missing, incomplete, or inconsistent.

Findings included:

Review of facility policy titled "Nursing Assessment/Reassessment," last revised date :08/2022, showed:

-H. Each department where nursing care is provided utilizes an interdisciplinary format individualized to the patient population served. Initial Assessment and Reassessment timeframe and criteria for each discipline are outlined in policy Appendix A.

Appendix A: Intermediate Care Units : criteria included: head-to-toe systems review; skin and wound assessment; review of systems performed by licensed personnel every shift.

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On 5/22/2024 on the IMCA unit; 2nd floor, (4) current patient electronic records were reviewed with Staff-F, RN. The review showed the following:

- Patient # 1: (four [4] random dates reviewed-both shifts ) : 5 shifts: no skin assessments documented; 1 shift -incomplete skin assessment

- Patient # 2 : (three [3 ] random dates reviewed-both shifts ) : 1 shift: documented presence of "skin alteration": no description of location, type, appearance, etc..

- Patent # 3: (four [4] random dates reviewed-both shifts ) : 2 shifts: no skin assessment documented.

- Patent # 4: (four [4 ] random dates reviewed-both shifts ) : 2 shifts: no skin assessment documented; 1 shift: documented presence of "skin alteration": no description of location, type, appearance, etc..


Patient # 8 ( discharged patient): review of patient skin assessments from 3/8/2024 through 3/22/24 (both shifts) showed inconsistent documentation and description of wounds on Patient # 8's toe, foot, and sacrum. Multiple shifts lacked documented nursing interventions related to the wounds. On three (3) shifts there was no documented skin assessment.

The above findings were verified by Staff-F, RN during the record review