HospitalInspections.org

Based on hospital policy review, medical record review, and interview, nursing services failed to identify and treat a hospital acquired skin tear for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "Pressure Injury Prevention and Management" policy effective 6/23/2021 revealed, "...A four eye assessment will be performed by two (2) RNs on admission and transfer level of care. This will include, but not be limited to...All abrasions, bruised, pressure injuries, lesions, petechiae, rashes, scars and tears...A photo of the wound must be taken on admission, at the time of occurrence, and at discharge and will be placed in the cart...Skin assessments will minimally be documented once a shift or via the admission/discharge policies..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 8/10/2022 with diagnoses which included Acute Rectal Bleeding unclear source, Acute Blood Loss Anemia secondary to Gastro-intestinal (GI) bleed. Patient #1's past medical history was significant for Liver Cirrhosis, Chronic Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Essential Hypertension, and Benign Prostatic Hyperplasia.

The Nursing Admission Assessment completed on 8/11/2022 at 4:00 AM revealed Patient #1 had bruising on his left and right arm, sacral redness, and a rash on his left and right lower legs.

The Nursing Integumentary Assessment completed on 8/11/2022 at 8:10 AM, revealed Patient #1 had bruising on his left and right arm and sacral redness.

The Physical Therapy (PT) Initial Evaluation dated 8/11/2022 at 9:50 AM revealed, Patient #1's "PT Integumentary Assessment: skin tear to (L) [left] elbow...Patient was found sitting on toilet and agreeable to evaluation; RN [Registered Nurse] informed PT upon entry to room that patient had just gotten out of bed by himself, pulled his IV out, and fell on the way to the toilet..."

A Nursing Narrative note dated 8/11/2022 at 11:59 AM revealed, "Phlebotomist stopped RN in hall to alert her to check on the patient. Patient found sitting on toilet, IV had been pulled out, blood running from IV site, and bright red blood in the toilet. Patient stated that he fell and hit his head on the wall and floor when he tried to get up to the bathroom..." There was no documentation of the skin tear on the patient's left elbow.

The Nursing Integumentary Assessment completed on 8/11/2022 at 8:00 PM revealed Patient #1 "Denies problems" and had sacral redness. There was no documentation of the bruising to the patient's arms and no documentation of the skin tear on the patient's left elbow.

The Nursing Integumentary Assessment completed on 8/12/2022 at 8:00 AM, revealed Patient #1 had "Abrasions" on his left and right arm and sacral redness. There was no documentation of the skin tear on the patient's left elbow.

In an interview on 10/10/2022 at 2:40 PM, the Physical Therapist was asked what she could recall about Patient #1. The therapist stated, "Exactly what I wrote. He was sitting on the toilet with blood on the floor and toilet...I spent most of my time cleaning up the mess. He had a skin tear. I'm not sure if it was new. I don't remember if it was actively bleeding or not..."

In an interview on 10/10/2022 at 3:28 PM, the Clinical Quality Improvement & Risk Management Director was asked if there was any nursing documentation of the patient's skin tear. The director stated, "I don't see anything about a skin tear."