HospitalInspections.org

Based on interview and document review the hospital failed to implement their policies and procedures for the comprehensive skin assessment of a patient's skin upon admission and for evaluating a patient's skin condition once each shift for changes in skin condition for 1 of 5 patient records reviewed (Patient #1).

Failure to implement the comprehensive skin assessment guidelines puts patients at risk for delays in receiving the appropriate medical care in a timely manner.

Findings included:

1. Review of the hospital policy titled " Nursing Procedures Comprehensive Skin Assessment", reviewed 04/19 showed that upon admission a comprehensive skin assessment was to be done "head to toe" and was to include the scalp and heels.

2. Review of Patient #1's medical record showed that:

a. The patient was admitted to the hospital on 08/24/20 as a transfer from another hospital for specialized treatment of orthopedic injuries sustained in a motor vehicle accident.

b. The admission skin assessment completed on 08/25/20 did not include an assessment of the patient's scalp.

c. On 09/07/20 the attending nurse discovered an occipital (back of scalp)wound. The attending nurse alerted the hospital wound care team to come assess the wound.

d. The Wound Care Nurse (WCN) assessed the wound. The wound was determined to be an injury caused by the patient's motor vehicle accident. Treatment for the wound was started on 09/07/20.

3. On 10/15/20 at 12:35 PM, the investigators interviewed the Wound Care Nurse (Staff #1). Staff #1 completed the initial assessment of the occipital wound after being alerted to the wound by the attending nurse. The wound was consistant with trauma from the motor vehicle accident and was not consistent with a pressure ulcer.

4. On 10/15/20 at 1:30 PM, the investigators interviewed the Wound Care Program Manager (Staff #2). Staff #2 verified the above information