HospitalInspections.org

Based on policy review, medical record review, and interview, in one out of six record reviewed, the hospital failed to ensure nursing staff documented an initial skin check on admission (Patient #1).

Findings Include:

Review of policy "Skin Integrity Management Policy," dated February 2024, indicated an initial skin check would be documented on admission and with transfer, where one nurse must be a registered nurse and another nurse must confirm.

Review of the medical record of Patient #1 revealed on 11/25/24 at 10:23 AM, Patient #1 presented to the emergency department via ambulance with a complaint of a fall and was found lying on the ground for four to five hours. The registered nurse noted a skin tear on Patient # 1's left lower leg, but no evidence was found to indicate an initial skin assessment was performed until 11/27/24 at 01:45 PM, when Staff (DD), Wound Care Nurse, documented a skin assessment for Patient #1 that identified one stage one pressure injury (reddened area of the skin) on the upper spine, a stage two pressure injury (skin breakdown where the top layer of skin has broken open) that measured 1.0 x 1.0 centimeter (cm), and a skin tear to the left lower leg measuring 3.6 x 3.1 x 0.1 cm deep.

Interview on 03/05/25 at 12:21 PM with Staff (DD), Wound Care Nurse, revealed they became involved in Patient #1's care on 11/27/24 when they performed a skin assessment for Patient #1. When Staff (DD) reviewed Patient #1's medical record, there was no initial skin assessment documented.