HospitalInspections.org

Based on document reviews and interview, it was determined, for 2 of 2 patient records reviewed (Pt. #1 and #2), the Hospital failed to document that patients were repositioned as a preventative and healthy skin care interventions as required by policy and physician order.

Findings include:

1. The Hospital policy titled, "Prevention and treatment of Pressure Ulcers and Non-Pressure Related Wounds" (release 6/16), required, "Pressure ulcer prevention intervention are initiated based on the Braden Scale risk factors, identified initially and ongoing.... Braden Scale .. is to help ...assess a patient's risk of developing a pressure ulcer by examining 6 criteria: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Shear. Each category is rated on a scale of 1 to 4 excluding "friction and shear" which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice versa. ...Prevention components...6 Preventive and healthy skin care interventions are utilized and may include but not limited to: a. reduce pressure, friction &shear...Repositioning interval...high risk patient are turned every 2 hours. "

2. The clinical record for Pt. #1 was reviewed on 10/4/16. Pt.#1 had 2 clinical records dated 7/31/16-8/17/16 and 8/26/16 to present. Pt. #1 was an 88 year old male, who was first admitted on 7/31/16, with acute respiratory failure; post tracheostomy and vent, currently has a tracheostomy collar. The history and physical (H & P) dated 7/1/16 indicated Pt. #1 had a suprapubic catheter and an unstageable sacral decubitus ulcer. Admission Braden dated 7/31/16 was 15 with subsequent scores ranging between 13-15 (moderate risk). Braden score for the admission on 8/26/16 to current ranged between 10 and 15 (high to moderate risk). A telephone order from the Attending Physician dated 7/31/16, included " Repositioning, start 7/31/16 (every 2 hours) " The clinical record lacked consistent repositioning every 2 hours. Examples are as follows:

- 8/1/16 between 1:00 PM 4:00 PM (3 hours)
- 8/5/16 between 1:22 AM-4:58 AM (3 hours 46 minutes)
- 8/13/16 between 10:00 PM to 8/14/16 at 8:00 AM (10 hours)
- 9/20/16 at 200 PM, Pt refused and no attempt documented until 8:00 PM
- 9/21/16 between 6:00 AM and 10:00 AM (4 hours)
- 9/23/16 between 12:00 PM and 4:34 PM(4 hours and 34 minutes)

3. The clinical record for Pt. #2 was reviewed on 10/4/16. Pt.#2 was a 73 year old male admitted on 9/9/16 with diagnoses of peripheral vascular disease, arterial vascular disease and status post above the knee amputation. Admission history included an un-stageable sacral decubitus ulcer. Braden score during the hospitalization ranged between 10-15 (high to moderate risk). The clinical record lacked consistent repositioning every two hours. Examples are as follows:

-9/19/16 between 2:00 PM and 6:54 PM (4 hours 54 minutes)
-9/22/16 between 12:00 PM and 6:21 PM (6 hours and 21 minutes)
-9/24/16 between 8:00 AM and 1:00 PM (4 hours and 59 minutes)
-9/26/16 between 8:11 AM and 12:15 PM (over 4 hours)

4. The above findings were discussed during record review and interview on 10/4/16 at approximately 1:00 PM, with the Director of Quality Management, who acknowledged that the repositioning should occur every two hours and are not being documented.