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Based on record review, staff interview and facility policy review the facility failed to notify the patient's family regarding two significant skin tears for one of five patients in the survey sample. (Patient #3)

The findings include:

Review of Patient #3's medical record revealed he was admitted to the facility on 02/24/2010. The admitting diagnosis included: acute respiratory failure, tracheostomy, unstageable decubitus, atrial fibrillation, diabetes, morbid obesity, fungal urinary tract infection, methicillin-resistant Staphylococcus aureus pneumonia, recurrent ileus and mucous plugging.

Review of Patient #3's wound care notes and pictures dated 03/18/2010 revealed pictorial documentation of two skin tears to Patient #3's lower extremities. Two different pictures dated 03/18/2010 presented two areas without the top layer of skin, beefy red in coloration with bloody drainage. The areas were approximately 4 cm (centimeter) in length. The pictures did not provide details for accuracy of location.

Review of the documentation and interview was conducted on 10/21/2010 at 3:19 p.m. with Staff #15, Registered Nurse Supervisor and Staff #2, the Chief Clinical Officer. Staff #15 reviewed Patient #3's medical record for notification of Patient #3's family related to a change in skin conditions. Staff #2 reviewed the pictures and stated "These are significant skin tears the family should have been notified."
Staff #2 directed Staff #15 to review other sections of the electronic record to determine if staff had charted notification of the family or notification of the physician in a different section. Staff #2 and Staff #15 were unable to locate documentation that Patient #3's family had been informed he sustained two "significant skin tears".

Review of the facility's policy titled "Change in Patient's Condition" listed "Injury" as a reason for the attending physician to notify the family and for the nurse caring for the patient to document notification in the nurse's notes.