HospitalInspections.org

Based on record review and staff interview it was determined the facility failed to provide assessments and documentation for patients with skin breakdown per facility policy for two (2) of two (2) patients who had documented skin breakdowns (patients #1 and 5). Failure to maintain assessment of a patient's skin breakdown when identified and failure to adequately document the event has the potential to adversely impact the immediate care, as well as the continuity of care, of all patients with skin breakdowns.

Findings include:

1. The nursing policy and procedure entitled, "Wound Care Management", last revised 2/13, states, in part: "A Stage One (1) pressure ulcer is intact skin with non-blanchable redness of a localized area usually over a boney prominence...all pressure ulcers are to be assessed and documented in the wound assessment [section] in the electronic medical record (EMR), and reassessed every three days with documentation in the EMR."

2. Review of the medical record for patient #1 revealed the patient was admitted with diagnoses that included dementia and combativeness. On 7/8/15, nursing documented the patient had a reddened skin area on his coccyx (tailbone), and she applied ointment to it. The record lacked an order for any treatment to the reddened skin area, which is identified as a Stage I pressure ulcer, per facility policy. There was no identification the reddened skin area was a pressure ulcer, or any reassessment of it in the patient's electronic medical record, nor any physician orders for treatment.

3. Review of the medical record for patient #5 revealed the patient was admitted with diagnoses that included dementia and agitation. Nursing documented the patient had a reddened skin area on his buttocks, and ointment was applied to it. The record lacked an order for any treatment to the reddened skin area, which is identified as a Stage I pressure ulcer, per facility policy. There was no identification of the reddened skin area, or any reassessment of it in the patient's electronic medical record, nor any physician orders for treatment.

4. An interview was conducted with the Clinical Manager on 7/29/15 at about 2:35 p.m. She reviewed the medical records of Patient's #1 and #5 and confirmed the findings stated above. She was unable to explain the lack of documentation, per policy, in the record. She stated her expectation would be to have the description of the reddened area, the assessment findings, physician orders for treatment, and the interventions implemented, documented in the medical record, per policy.