HospitalInspections.org

Based on document review and interview, the facility failed to ensure wound/skin assessments were completed and were accurate for 1 of 10 medical records reviewed (Patient #1); and failed to notify Physician/family/guardian of patient injuries, falls and wounds/skin issues for 1 of 10 medical records reviewed. (Patient #1).

Findings include:

1. Facility policy titled "Wound Care and Treatment", PolicyStat ID: 12385988, last revised on 9/2022 indicated the following: "PURPOSE: To ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. POLICY: B. The medical provider will be notified upon identification of a wound or skin related issue. If consent is given, the family or legal representative will be notified of new skin breakdown post admission. PROCEDURE FOR WOUND TREATMENT: 1. A treatment order will be obtained upon identification of a wound.

2. Facility policy titled "Skin Assessment", PolicyStat ID: 12385990, last revised on 9/2022 indicated the following: "PURPOSE: 1. To provide proper skin assessment guidelines for nursing staff. 2. To identify any existing or new wounds, injuries, bruises, skin conditions, self-harm behaviors, and/or contraband. POLICY: The guidelines in this policy are to identify and document any areas of concern related to patient skin. PROCEDURE: Assessment: 1. Additional skin assessments should be completed one time per week or as ordered by provider. 2. The assessment process should include: e. Identification of any wounds, injuries, bruises, skin conditions, self-harm behaviors, and/or contraband.

3. Facility policy titled "Assessment/Reassessment", PolicyStat ID: 12386392, last revised on 9/2022 indicated the following: "PURPOSE: To ensure that all patients receive the appropriate screening, assessment, and reassessment by qualified individuals within the organization. The assessment process will be continuous, collaborative effort with all of the health care members functioning as a team. Communication among the health care team is an essential element of the assessment process. POLICY: 5. Assessment is ongoing as appropriate throughout the hospital stay. 7. Nursing will re-assess each patient every shift and as warranted by the patient's medical condition and document findings.

4. Review of Patient #1's medical record indicated the following:
(A) The patient was admitted on 10/26/24 at 11:35 a.m. and left AMA (Against Medical Advice) with (Family Member #2) on 10/9/24 at 1:35 p.m.

(B) The patient's nursing admission assessment dated 10/26/24 at 11:35 a.m. indicated the patient's skin was intact with no skin issues upon admission to the facility.

(C) A review of a nurse's note for Patient #1 dated 11/5/24 at 7:55 p.m. indicated the following: At around (7:45 p.m.) pt. was crawling around on (his/her) floor and informed writer (he/she) hit (his/her) head on the wall. 1 inch swelling on (his/her) L (left) forehead. The medical record lacked documentation that a provider and/or Patient #1's family/guardian were notified of the incident/wound.

(D) A review of a nurse's note for Patient #1 dated 11/6/24 at 12:57 p.m. indicated the following: Patient walking in milieu, slipped/tripped over own feet, fell to (the) floor, witnessed by staff. Pt. able to move all extremities w/o (without) difficulty, did not hit head. Assisted (Patient #1) up to chair by staff. The medical record lacked documentation that a provider and/or Patient #1's family/guardian were notified of the fall.

(E) The patient's nursing skin assessments indicated the following:
(a.) On 11/6/24, dayshift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments.

(b.) On 11/6/24, Patient #1's medical record lacked documentation of a skin reassessment on night shift by nursing staff and/or patient refusal of a skin assessment.

(c.) On 11/7/24 and 11/8/24, dayshift and night shift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments.

(d.) On 11/9/24, Patient #1's medical record lacked documentation of a skin reassessment on day shift by nursing staff and/or patient refusal of a skin assessment.

5. During a phone interview with NP2 (Nurse Practitioner/Adult Gerontology) with A2 (Chief Executive Officer) present on 1/16/25 at 1:52 p.m., NP2 verified the lack of documentation in (his/her) provider notes related to Patient #1's incident on 11/5/24, where the patient hit (his/her) head on a wall, a contusion on the patient's forehead and incident on 11/6/24, where the patient had a witnessed fall and/or any additional skin issues of black eyes.

6. During an interview with A1 (Market Director of Quality/Risk) on 1/16/25 at 2:40 p.m., A1 verified the lack of documentation in Patient #1's medical record related to bruising to the patient's eyes and/or head. A1 verified the lack of documentation of skin reassessments for Patient #1's one inch contusion from an incident on 11/5/24. A1 verified that the medical record lacked documentation that the provider and/or guardian were notified of Patient #1's incidents on 11/5/24, where the patient hit (his/her) head on a wall and on 11/6/24, where the patient had a witnessed fall without injury. A1 verified that incident reports are not part of a patient's medical record.

7. During an interview with N8 on 1/16/25 at 3:20 p.m., N8 indicated that (he/she) did not remember Patient #1 having any black eyes, but did remember that the patient had a bruise that was more on the left side of (his/her) forehead that went down the side of (his/her) head to (his/her) eyebrow. N8 indicated that the bruise was green/yellow in color.

8. During an interview with N13 (Registered Nurse) on 1/16/25 at 4:00 p.m., N13 indicated that Patient #1 had bruising to (his/her) forehead and possibly to at least one of (his/her) eyes. N13 indicated that the bruising was in different stages of healing, the center of the bruising was darker and then it got lighter as it went outwards.

9. During an interview with N14 (Registered Nurse) on 1/16/25 at 4:10 p.m., N14 indicated that Patient #1 did have bruising to (his/her) forehead and to both (his/her) eyes from underneath their eyes up. N14 indicated that (Family Member #2) was upset that (he/she) was not notified of Patient #1 hitting (his/her) head on the wall and the bruising.