HospitalInspections.org

Based on document review and interview, the nursing staff failed to develop and utilize an ongoing individualized plan of care based on standards of care for each patient, for 1 of 10 MR's (Medical Record) reviewed. (Patient # 7).

Findings include:

1. Review of hospital policy titled: "PLAN OF CARE", policy/procedure number: NDM.14.15, indicated on page 1, under Policy Statement/Purpose:, 1.0 "plan of care shall be identified by the RN" (Registered Nurse), 2.0 "based on the prioritized needs of the patient"; identified through physical assessments"; 3.0 "planning of interventions", 3.2 "Care plan goals". Last reviewed 5/2022.

2. Review of hospital policy titled: "Pressure Injury Prevention", policy number: SKN 22.10, indicated on page 2, under Pressure Injury Risk Assessment; point 3, "For a score of 18 or less, or per clinical judgement, a Care Plan inclusive of preventative measures will be initiated". Date effective: 3/2021.

3. Review of Patient # 7 MR, indicated the following:
A. Patient # 7 admitted on 12/4/2022 for confusion, and diagnoses of Sepsis secondary to UTI (Urinary tract infection), possible left pneumonia and Acute kidney injury.
B. Nursing flowsheets reflected patient's braden scale of 17 on admission (12/4/2022) skin assessment and braden decreased to 15 on 12/17/2022 and remained at 15 on day of discharge (12/29/2022). Patient's skin assessment on admission noted skin warm and dry; area of redness to buttocks; blanchable = yes. Skin assessments reflected redness to sacrum into 12/14/2022. Skin alteration noted on 12/14/2022 at 4:04 am; pressure area to sacrum. Wound care nurse note on 12/20/2022 at 10:32 am, reflected pressure injury sacrum; first assessed 12/14/2022; 4.5 cm (centimeter) - (width) x 3.5 cm depth; unstageable.
C. Patient care plan did not indicate area for skin integrity; initial and/or updates; for prevention measures and interventions; during hospital stay.

4. In interview on 3/7/2023 at approximately 11:20 am, and at approximately 12:30 pm, with administrative staff member A # 3 (RN {Registered Nurse} - Manager Nursing Quality), confirmed the following:
A. Verified no skin integrity on plan of care, for patient # 7.
B. Care plan should have been updated for skin, on 12/14/2022, with skin wound that had been assessed, and additional interventions by staff.