HospitalInspections.org

Based on staff interviews and record review it was determined the nursing staff failed to develop and keep current a nursing care plan to prevent skin breakdown for 1 (#2) of 10 sampled patients. This practice does not ensure patient needs are met and may prolonged a hospital stay.

Findings Include:

1. Patient # 2 was admitted on 3/30/2012 for compromised ventilation and sepsis. The nursing assessment documented the patient's skin to be "intact" daily until 4/20/12. On 4/20/12 the nurse documented a dressing to the sacrum and a reddened area to the left heel. A review of the patient's care plan and problem list dated 4/18/12 through 4/21/12 identified the patient's problems as: Ineffective Breathing, Pain/Chest Tube/Post Surgery, Risk for Falls, Inadequate Oral Intake and Restraint Use. The care plan did not address the potential for skin breakdown for the ventilator dependent, post operative, total dependent patient.

The record review and interview of the Cardiovascular Intensive Care Unit Nurse Manager and the assigned nurse on 5/10/12 at 2:10 p.m. revealed the wound management service was obtained on 4/19/12, after the sacral open area was identified. No further care plan information was available upon request.