HospitalInspections.org

Based on document review and interview it was determined the facility staff failed to ensure 2 of 8 medical records (Patient #5 and #8) was complete and accurate. Three physicians progress notes in Patient #8's medical record written on the same date had different information related to pressure sores. Patient #5's Nursing Assessment Sheets for 11 days contained different information or no information about Patient #5's skin assessment.

The findings include:

Patient #8 and #5's medical records were reviewed on 4/11/17 and revealed the following information:

Patient #8 was readmitted to the facility on 1/26/17. The history and physical dated 1/27/17 by the attending physician stated decubitus ulcer of sacrum, necrotic unstageable. The attending physician wrote in the progress note dated 1/31/17 and 2/1/17 Patient #8 had no wounds. On 1/31/17 the physician directing wound care wrote stage 4 pressure wound to the sacrum of 4 days duration. On 1/31/17 a third physician wrote large pressure sore unstageable. The registered dietician wrote on 2/1/17 Patient 8 had a stage 4 pressure sore to the sacrum and a stage 2 pressure sore to the trach site.

Patient #5 was readmitted on 3/30/17. The Nursing Admission Assessment form dated 3/30/17 at 18:17 (6:17 P.M.). identified three stage 3 decubiti on the sacrum and buttock. Patient on a LAL mattress (low air loss) The following was documented on subsequent Nurse Assessment Sheets under the Skin Assessment section:
3/30/17 at 7:40 P.M. no documentation
4/1/17 at 20:45 (8:45 P.M.) documents skin impairment: none
4/4/17 at 07:00 documents skin impairment: excoriation (an abrasion of the epidermis). There is no intervention identified. A stage 3 pressure sore as described by WebMD.com is: the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. LAL mattress.
4/4/17 at 23:00 (11:00 P.M.) documents nothing except Patient #5 is on a static mattress
4/5/17 at 22:00 (10:00 P.M.) documents skin impairment: none
4/7/17 at 07:00 A.M. documents skin impairment: excoriation
4/7/17 at 21:00 (9:00 P.M.) no documentation except type of mattress as LAL
4/8/17 at 08:00 A.M. no documentation except type of mattress as LAL
4/8/17 at 19:30 (7:30 P.M.) documents skin impairment: none, type of mattress LAL
4/9/17 there is no A.M. Nurse Assessment Sheet
4/9/17 at 19:30 (7:30 P.M.) documents skin impairment: none, type of mattress LAL
4/10/17 there is no A.M. Nurse Assessment Sheet
4/10/17 at 21:30 (9:30 P.M.) documents skin impairment: nothing checked, there is a comment in the other section but it is not legible.

On Staff Member #2 explained on 4/11/17 that a head to toe assessment is performed every 24 hours on every patient. A "Four Eyes Skin Assessment" is performed every shift by 2 nurses. Staff Member #2 stated, "We need to work on our documentation."