HospitalInspections.org

Based on review of documentation, observation, and interview, the hospital failed to ensure that skin assessments were conducted within 8 hours of admission by a registered nurse for patients with pressure injuries or in need of wound care; failed to ensure that daily skin and wound inspections were completed by an RN for patients with pressure injuries, and failed to ensure that plan of care included pressure injuries when patients had pressure injuries. This presents a risk that pressure injuries may not be assessed or treated and these findings were not in accordance with facility policy.

Findings included:

Medical records of 10 patients with pressure injuries were reviewed the morning and afternoon of 3/5/19 in the hospital conference room with Staff #1, Staff #3, and Staff #5.

There was no documentation of a skin assessment within 8 hours of admission by a registered nurse for Patient #1 (admitted 5/24/18) and Patient #8 (admitted 12/13/18).

There was no daily documentation of skin and wound inspection completed by an RN. There was documentation by an LVN, but no assessment by an RN for 3 patients with pressure injuries on the following dates:
Patient #1: 6/2/18, 6/3/18, 6/4/18, 6/5/18, 6/8/18, 6/9/18, 6/12/18
Patient #6: 1/22/19
Patient #7: 12/30/18

There was no daily documentation of any skin and wound inspection completed by an RN for the following 5 patients:
Patient #2: 2/24/19, 3/2/19
Patient #4: 1/1/19
Patient #6: 1/23/19, 1/25/19
Patient #7: 1/23/19
Patient #10: 1/23/19, 1/24/19, 1/28/19

There was no documentation of pressure ulcer treatment or wound care in the plan of care for Patient #1 and Patient #8.

Hospital policy, "Wound Assessment, Prevention, and Documentation" last reviewed 8/14/2018, stated, in part, "All patients admitted to the hospital will be screened within 8 hours for risk of skin breakdown and for alteration in skin integrity by a registered nurse ...
I. Assessment
An RN will inspect each patient's integument daily, weekly and as often as indicated ...
2. Pressure injuries are noted in the record upon discovery (either upon admission or throughout the stay).
A. A full assessment is completed within 8 hours of admission (or discovery of a new wound) to include descriptions, measurements, photos, and physician notification. This will aid in communication with the treatment team prior to staging determination.
B. Wounds will be staged by designated clinicians within 2 days of discovery...
D. Within 2 days before discharge a final complete assessment is conducted, including descriptions, staging, measuring, and photography as appropriate...
III. Documentation...
2. Daily documentation of skin and wound inspection completed by an RN will include any of the following, if present:
A. skin condition.
B. dressing integrity.
C. description of wound drainage, odor, pain, signs of inflammation or infection, if present.
3. Daily documentation will be recorded by the RN as part of the daily nursing assessment ..."

Hospital policy, "Care Planning", last reviewed 8/14/2018, stated, in part, "All inpatients will have a plan of care developed by the interdisciplinary team (IDT) responsible for their care ...
It is the policy of the hospital that each patient admitted will have an IPOC (Interdisciplinary Plan of Care) developed, which will be based on his/her assessed individual needs ...
1. the RN will initiate the IPOC within 24 hours of admission on each patient. The evaluating Interdisciplinary Team (IDT) and rehab physician will complete the IPOC following patient assessment, by day 4 ...
4. Each body system or functional area with identified problems will be followed by specific interventions designed to meet the needs of the patient..
11. Updates to the IPOC are documented in the plan. Any new problems or interventions are identified and initiated."

The above findings were confirmed during the medical record and policy review the morning and afternoon of 3/5/19 in the hospital conference room with Staff #1, Staff #3, and Staff #5.