HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 2 of 6 MRs reviewed of patients at risk for skin breakdown, (Patient #1 and Patient # 2) documentation by nursing pertaining to skin assessment was inconsistent and /or lacking. This could cause untoward patient outcomes.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled, "Skin Integrity and Pressure Injury Prevention and Treatment," last revised 5/2021, indicated the registered nurse (RN) should complete all the required assessments and ensure that prevention measures and treatments comply with guidelines. On admission a head to toe skin assessment and Braden score should be done. Every shift a head to toe skin assessment should be done.

-- Review of Patient #1's MR revealed, she was a 95-year-old female admitted on 4/6/2022 with a diagnosis of sepsis, acute cholecystitis and perihepatic ascites. Nursing documenation from 4/6/2022 to 4/8/2022 did not identify any skin breakdown or other skin issues.

On 4/8/2022 nursing documentation revealed:
- 8:00 pm - (after a cholecystectomy was performed) skin warm and dry, bruising and redness scattered left upper cheek, open non-blanchable. Epidermis thin with loss of subcutaneous tissue.

On 4/9/2022 nursing documentation revealed:
- 3:00 am - no skin issues documented
- 9:00 am - scattered bruising documented
- 9:00 pm - skin warm and dry, bruising and redness scattered, left upper bottom, open non-blanchable. Epidermis thin with loss of subcutaneous tissue (25 hours after skin breakdown first identified and documented).

On 4/10/2022 nursing documentation revealed:
- 3:00 am - no skin issues identified
- 5:17 am - Menthol-zinc oxide ordered 4 times daily, apply a thin layer to the affected area (no documentation of use).
- 9:00 am - scattered bruising documented
- 10:00 pm - skin warm and dry, bruising and redness scattered, bottom, open non-blanchable. Epidermis thin with loss of subcutaneous tissue (25 hours later from last skin breakdown documentation).

On 4/11/2022 nurisng documentation revealed:
- 9:30 am - deep tissue pressure injury (DTPI). (No additional description.)

At 1:57 pm, wound care consultant documented Patient #1 has a DTPI on left sacrum. Site is denuded, fragile, red and purple. Shape is irregular, wound length is 5 centimeters (cm), width is 7 cm, serous drainage present. Wound care treatment ordered.

-- Review of Patient #2's MR revealed, a 90-year-old female admitted on 8/4/2022 with a diagnosis of fractured left femur. She remained in the emergency department (ED) until after surgery on 8/5/2022 and then was admitted to the nursing unit. The history and physical (H&P) documented by the provider indicated Patient #2's skin was intact. The nursing admission assessment was completed at 11:00 pm revealed no skin breakdown. Nursing documented turning and positioning (T&P) of patient every 2 hours (q 2 h).

On 8/6/2022 at 1:30 pm nursing documented a stage 2 pressure injury on sacrum and a wound care consult was ordered. (This is first documentation of skin breakdown on Patient #2's sacrum.)

Wound care consult was completed on 8/8/2022 and additional interventions were put in place e.g., barrier cream, mattress pump and frequent positioning.

-- Per interview of Patient #2 on 8/9/2022 at 10:50 am, she had a sacral wound prior to admission which she had been putting ointment on at home.

-- During interview of Staff A, Director of Quality Management on 8/11/2022 at 1:00 pm, he/she acknowledged the above findings.