HospitalInspections.org

Based on record review and interviews, the registered nurse responsible for supervision and evaluation of the nursing care failed to ensure that care was provided in accordance with hospital policy as evidenced by: 1) failing to ensure an incident report was completed for 1 (#2) of 5 (#1-5) records reviewed for incident reports; 2) failing to ensure skin assessments were completed for 2 (#1 and #2) of 5 (#1-5) records reviewed for skin assessments; 3) failing to ensure patient wound or injuries were photographed and placed in the medical record for 1 (#1 )of 5 (#1-5) records reviewed for photographs. 4) failing to ensure a neurological exam was completed on 1 (#1) of 1(#1) records reviewed for neurological exams after head trauma.

Findings:

A review of the Hospital Policy titled Skin/ Wound Care last revised 12/01/2021 revealed in part:
Skin Assessment:
1. A skin assessment is completed by the registered nurse on all patients at admission, weekly, after a fall/ injury, upon new skin findings and at discharge.

Wound Care Procedure:
1. If a patient is identified to have a wound, wound photography is performed and documentation of the wound is completed on the hospital skin assessment wound care documentation form, or in the designated portion of the electronic medical record (EMR), as applicable.

A review of the Skin Assessment & Wound Care Documentation form revealed in part:
Nursing: To be completed at admission, weekly, after a fall or injury, or new findings. Please review previous documentation to assess for change, improvement, or worsening.

Review of hospital policy titled, "Fall Assessment/ Re-Assessment and Precautions," revised 02/01/2021, revealed in part, "Post fall interventions shall include: · RN physical assessment of the patient, · Obtain vital signs including pain assessment, · Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury, · Notify Physician/ Non-physician practitioner (NPP) and obtain further orders as needed."

Review of hospital policy titled, "Neurological Assessment," revised 12/01/2020, revealed in part, "Neurological Assessment will be initiated immediately after an unwitnessed fall or fall with possible head injury. This included a continuation of neuro checks to be completed after return from Emergency room due to fall if patient returns within 24 hours of the fall."

1.) Failing to ensure an incident report was completed for 1 (#2) of 5 (#1-5) records reviewed for incident reports

A review of the June 2021 incident failed to reveal an incident report for Patient #2.

In an interview on 08/25/2021 at 2:35 p.m. S3RN stated she failed to complete an incident report related to the bruising on Patient #2's face as noted in the photos dated 06/27/2021 1:48 p.m.

In an interview on 08/26/2021 9:00 a.m. S2DON stated the incident with Patient #2's facial bruising should have had an incident report completed because it was new changes to her skin. S2DON also stated she reviewed the incident folder for June 2021and it did not contain an incident report for Patient #2.

2 Failing to ensure skin assessments were completed for 2 (#1 and #2) of 5 (#1-5) records reviewed for skin assessments.

Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted on 08/20/2021 and experienced a witnessed fall on 08/23/2021 at 8:10 a.m. with head trauma and bleeding.

Further review of the medical record revealed no documentation of the wound on the skin assessment wound documentation form.

In interview on 08/26/2021 at 11:15 a.m., S2DON verified the wound was not documented per policy in the medical record on the skin assessment form.

Patient #2
A review of Patient #2's MR revealed she was admitted on 06/19/2021 at 1:08 p.m.

A review of Patient #2's medical record revealed time stamped photos revealed the photos were taken 06/19/2021 at 1:13 p.m. upon admission with bruising throughout her body. Further review revealed another photo was taken on 06/25/2021 at 4:27 p.m. and Patient #2's facial bruising looks better than on admit. Patient #2's medical record also contained several photos dated 06/27/2021 at 1:47 p.m., which revealed more bruising to the left side of Patient #2's face.

Further review of Patient #2's medical record failed to reveal documentation of the wounds as noted in the photos dated 06/27/2021 at 1:47 p.m. on the hospital skin assessment wound care documentation form, or in the designated portion of the medical record.

In an interview on 08/25/2021 at 1:00 p.m., S2DON stated she was familiar with Patient #2 and the nurse who took the pictures dated 06/27/2021 at 1:48 p.m. failed to complete a new Skin Assessment & Wound Care documentation form.

In an interview on 08/25/2021 at 2:35 p.m., S3RN admitted she took the pictures of Patient #2 dated 06/27/2021 at 1:48 p.m. and she failed to complete the Skin Assessment & Wound Care Documentation form or document the assessment in Patient #2's medical record.

3) Failing to ensure patient wound or injuries were photographed and placed in the medical record for 1 (#1) of 5 (#1-5) records reviewed for photographs

Patient #1
Review of the medical record for Patient #1 revealed he was admitted on 08//20/2021 experienced a witnessed fall on 08/23/2021 at 8:10 a.m. with head trauma and bleeding. Patient #1 was transported to the emergency room for evaluation returned to the facility later that day.

Further review of the medical record revealed no photographs taken before or after Patient#1 was evaluated in the emergency room.

In interview on 08/26/2021 at 11:15 a.m., S2DON verified no photographs were not taken as per hospital policy.

4) Failing to ensure exam was completed on 1 (#1) of 1 (#1) records reviewed for neurological exams after head trauma.

Patient #1
Review of the medical record for Patient #1 revealed he was admitted on 08//20/2021 experienced a witnessed fall on 08/23/2021 at 8:10 a.m. with head trauma and bleeding. Patient #1 was transported to the emergency room for evaluation returned to the facility later that day.

Further review of the medical record revealed that a neurological assessment was not performed immediately after the fall and in the 24 hours after the incident as per hospital policy.

In interview on 08/26/2021 at 11:15 a.m., S2DON verified the neurological assessment was not performed per hospital policy immediately after the fall and for 24 hours after the incident.







44495

Based on record review and interview, the hospital failed to ensure nursing care plans were revised to meet the patient's needs. This deficiency is evidenced by failure of the nursing staff to revise the nursing care plan for 2 (#1 and #3) of 5 (#1-5) records reviewed for care plan completeness.

Findings:

Patient #1
Review of the medical record for Patient #1 revealed a witnessed fall on 08/23/2021 at 8:10 a.m.
Further review of the medical record revealed that his fall risk assessment changed from moderate to high risk. Review of the Multidisciplinary Plan for Patient #1 revealed no new interventions implemented and no changes after the documented fall.

Patient #3
Review of the medical record for Patient #3 revealed falls on 08/11/2021 at 4:55 p.m., 08/12/2021 at 2:20 a.m., and 08/12/2021 at 2:30 p.m.
Further review of the medical record and Multidisciplinary Plan revealed no new interventions implemented and no changes made after the documented falls.

In interview on 08/26/2021 at 11:15 a.m., S2DON verified the care plans for Patient #1 and Patient #3 were not revised to meet each patient's needs.








44495