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Based on the review of policies and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that the nursing staff adhered to the facility's policies, procedures, and protocols when it was determined that patient (P) (P#1) sustained blistering to the skin as a result of tape use despite prior documentation of P#1's allergy to tape.


Findings include:

A review of the facility's policy titled "Assessment and Reassessment of Patients," effective 2/22/24, revealed that the purpose of the policy was to identify initial assessment and reassessment components of the patient's condition by assigned discipline. Patient assessment and reassessment would be done by all disciplines managing aspects of the patient's care. The hospital would provide each inpatient with an appropriate assessment of the patient's condition and needs at the time of admission in accordance with the Hospital's Medical Staff Bylaws and Rules and Regulations.

A review of the facility's policy titled "Nurse-Driven Skin Care Prevention and Management," effective 2/28/24 revealed that the purpose of the policy was:
a. to document and track pressure injuries that were present on admission to hospital.
b. To prevent and manage skin breakdown and injuries.
c. To promote and maintain general skin health.
d. Patient/family/care partner verbalizes understanding of skin breakdown causes and preventative skin care measures by discharge.
i. To provide a systematic, and ongoing assessment tool to identify patients with altered skin integrity and those at risk for development of skin impairments.
ii. To provide nursing personnel guidelines for planning and evaluating appropriate interventions for patients with or at risk for skin breakdown.

A review of Patient (P) P#1's medical record revealed that P#1 arrived at the facility on 1/11/24 at 8:12 a.m. for an elective surgery with a pre-operative diagnosis of Spondylosis without myelopathy or radiculopathy, lumbar region (wear and tear affecting the lumbar spine and the sacrum).
Documentation under the problem list on 1/11/24 at 8:12 a.m. revealed that P#1 was scheduled for Lumbar Anterior Interbody Fusion (surgery to fuse together the painful or unstable vertebrae so that they heal into a single solid bone) on 1/11/2024.

A review of the skin assessment under the progress notes on 1/11/24 revealed a Wound 1/11/24 - Incision Abdomen Lower -Dressing Status: Clean, Dry Intact.

A review of the nursing flowsheets on 1/12/24 at 9:13 a.m. revealed dressing status of only Tegaderm applied/no blue patch (a thin clear sterile dressing that keeps out water, dirt and germs yet lets skin breathe).

A review of the nursing flowsheets on 1/17/24 at 4:04 p.m. revealed that P#1 had an ecchymosis (bruise) on the upper face, which was not present on admission. Documentation revealed no drainage, no odor, and the dressing status was Open to Air.

A review of the nursing progress notes on 1/25/24 at 7:41 p.m. revealed that P#1's abdomen was distended with dry blood-stained dressing to lower abdomen and superficial dry wounds to abdomen as a result of reaction to adhesive tapes as per report.

A telephone interview took place in the conference room on 5/1/24 at 1:40 p.m. with Registered Nurse (RN) DD who stated that she could not recall P#1. RN DD stated that if a patient was allergic to tape, then the staff would take necessary precautions to ensure the patient was not exposed to it. RN DD stated that she could not recall if a tape was used to secure P#1's dressings.

RN EE stated that P#1 had a wound on his head that was dried up, and she got report that the wound was from the cooling wrap.

During the exit conference on 5/1/24 at 3:30 p.m., COO/CNO II reiterated that it is difficult not to use a tape on a patient, especially one with an extensive abdominal surgery as it is quite challenging to secure a dressing in place without the use of a tape.