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Based on record review, staff interview and review of approved hospital policy and procedure, the hospital failed to ensure that staff consistently provided a periodic and comprehensive assessment and reassessment of patients skin condition in order to plan and implement effective interventions to prevent and/or treat skin breakdown for 2 of 8 patient records reviewed (Patients # 4 and #5).

Failure to comprehensively reassess patient ' s skin condition and plan appropriate care interventions risked patient health and safety through unidentified and/or undocumented lesions that were not consistently treated to prevent further breakdown.

Findings:

Patient #4 was admitted on 12/28/2010 for chest pain. The 56 year old had a history of morbid obesity, Type 2 diabetes using insulin, and right femoral-popliteal bypass surgery in 1999. S/he was admitted with multiple skin issues including yeast infection, a chronic sacral wound, bilateral buttocks wounds and additional excoriations and open abdominal wounds. Skin care consultation was requested on 12/28/2010.

The patient remained in the hospital until 1/7/2011, and was discharged to a skilled nursing facility. Review of the patient's skilled nursing facility admission record dated 1/7/2011 evidenced necrotic wounds between the patient's toes: "Right 4th and 5th toe with necrotic 0.5 x 0.5 cm stage IV and left foot 1st and 2nd toe 0.5 cm x 0.5 cm Stage IV and 2nd and 3rd digits 0.1 x 0.1 cm stage IV." The foot wounds were not documented or described on the transfer record from the hospital. There were no recommended treatments identified for the foot wounds as there were for the abdominal wounds.

The hospital policy, "Skin Care, Wound Care and Pressure Ulcer Prevention Guidelines" (#PFF-59) was reviewed. The Policy read, "It is the policy of Central Washing Hospital that skin integrity be assessed by the nurse on all patients within 24 hours of admission, ongoing as per unit standards of care, at time of discharge, and prn due to change in skin condition...." The Purpose of the policy was defined as, "Identify patients with potential for or actual impairment in skin integrity. Define optimal interventions for the prevention and treatment of skin breakdown."

Staff explained during interviews on 3/22-23/2011 that skin care was handled by staff RNs, the wound care/ostomy RN, and the wound care Physical Therapist. Review of progress notes evidenced on-going nursing assessments and care of the abdominal and sacral wounds. The patient was discharged to a Skilled Nursing Facility (on 1/7/2011, approximately 10 days after admission). The Wound Care Transfer Summary information sheet documented abdominal wound care, and identified heels and coccyx at "high risk for injury."

Nursing staff and specialty nursing and physical therapy wound care staff failed to comprehensively assess the patient to include a "head to toe" assessment on each shift for up to 10 days after admission. The patient's history of diabetes and circulatory impairment (femoral-popliteal bypass surgery) required on-going, careful assessments of legs, feet, and toes. Staff failed to follow hospital policy and standards of nursing practice during the inpatient stay and discharge of this patient.

Patient #5 was an 80 year old admitted on 1/17/2011 for a lung biopsy. An assessment at 1300 (1 pm) on 1/17/2011 identified skin as being bruised, dry, fragile, intact, and non-elastic. Pre-op skin condition was documented as "warm, dry, intact."

Nursing documented following the procedure on the Operative Summary: "Patient had skin tear to right lateral chest intraoperatively due to removal of tape. ...Bruising observed on right chest where adhesive drapes were removed at procedure end. During transfer off of OR (operating room) table skin tears were noted to right forearm, left hip, left upper arm, and left chest...Small skin tear occurred where paper tape was removed from left eyelid..."

The purpose of the approved skin care hospital policy, "Skin Care, Wound Care and Pressure Ulcer Prevention Guidelines" (#PFF-59) was defined as to, "Identify patients with potential for or actual impairment in skin integrity. Define optimal interventions for the prevention and treatment of skin breakdown."

Admitting and operating room staff failed to formulate and implement care plan interventions to protect this patient's skin from injury, pain and the potential of infection.


Nursing staff failed to provide comprehensive patient care based on an individualized assessment/reassessment for each patient, and implementation of appropriate, consistent care plan interventions to prevent avoidable harm.