HospitalInspections.org

Based on clinical record review, staff interview, and facility policy review. It was determined that the facility failed to always assess and to document care and treatment related to the patients' skin integrity issues.
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Findings included:
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Facility policy titled "Skin/Wound Care" states in part, "Procedure: Skin Assessment
1. A skin assessment is completed by the registered nurse on all patient at admission, weekly, after a fall/injury, upon new skin findings and at discharge.
2. Description of skin abnormalities should be documented according to assessment findings including the initiation of the impaired skin integrity treatment plan.

Clinical record for patient #1 revealed the "Daily Nurses Notes" skin assessment section "wound" was checked on 4 (four) different dates and 5 (five) different times. No other documentation was noted and no describe of the wound noted in the patient's clinical record.

In an interview with the ADON she confirmed the above findings. She stated documentation concerns would be discussed in a nurses meeting tomorrow (5/01/19).