HospitalInspections.org

Based on document review and interview the facility failed to ensure accurate skin assessments were completed in one ( patient 1's medical record) of 10 medical records reviewed.

Finding include:

1. Policy titled Pressure Ulcer Prevention/ Pressure Ulcer Risk Assessment last reviewed/revised 9/6/2016 states on page 1: "6. The licensed nurse will complete an integumentary assessment every shift and document results in the Daily Nursing Record."

2. The daily assessment sheets dated 5/1/17 indicated the patient was sent to the emergency department (ED) for a laceration to the forehead. The skin assessments lacked further documentation of the laceration to the forehead until 5/6/17. The medical record indicated the patient had a sacral wound on 5/5/17 and the skin assessments on 5/5/17 and 5/6/17 lacked documentation related to the sacral wound.

3. Interview on 7/14/2017 at approximately 10:50 a.m. N3 confirmed the medical record lacked consistent charting on skin assessments in patient 1's medical record.