HospitalInspections.org

Based on document review and interview, the registered nurse failed to follow the facility policy and procedure ensuring a skin assessment was completed within eight (8) hours of a patient's admission, a skin assessment completed per shift, and a physician order verified for one (1) of ten (10) patients. (Patient # 10)

Findings include:

1. Review of the facility policy titled, "Wound Assessment (CIRH)", Policy number WC II-2, indicated all patients admitted will have a skin assessment within eight (8) hours of admission and the skin would be assessed every shift. This policy was last revised in 04/2021.

2. Review of the facility policy titled, "Guidelines and Protocols, Clinical", Policy number S05-G, indicated the registered nurse should verify information obtained in report with kardex and written physician order and ascertain accuracy in patient room to be completed every twelve (12) hours after receiving report. This policy was last revised in 04/01/2022.

3. Review of patient # 10's medical record (MR) indicated the patient was readmitted to H # 2's (Long Term Acute Care Hospital) on 02/05/2022 at 9:12 am. The skin assessment was documented on 02/06/2022 at 2:46 pm and the wound orders were verified on 02/06/2022 at 2:46 pm.

4. In interview dated 04/13/2022 at approximately 3:45 pm with A # 1, confirmed the day nurse failed to complete a skin assessment within the eight (8) hours of the patient's admission, the evening/night nurse failed to complete a skin assessment, and they both should have. The charge nurse missed getting the wound care order verified upon admission.