HospitalInspections.org

Based on interview and record review, the hospital failed to ensure there was documented evidence the nursing care plan for 3 of 4 sampled patients (#1, #3, #4 ) was implemented.

The findings include:
1. Patient #1 was admitted to the hospital on 2/3/11 with 3 identified Stage III, possibly Stage IV pressure wounds on the right and left ischial and sacral area.
The Nursing Care Plan initiated at admission included Turning and Repositioning every 2 hours.
On 4/27/11 at approximately 11:30AM, review of the electronic record and an interview with Nurse #1 was conducted. The data entered into the Nursing Flowsheet regarding the repositioning on 4/25/11 and 4/26/11 revealed the repositioning of this patient was not entered every 2 hours, as per the Nursing Plan of Care.

2. Patient #3 was admitted to the hospital on 3/28/11 and was assessed as a Fall Risk.
On 4/27/11 at approximately 2:00PM, with the assistance of Nurse #2, the electronic Nursing Care Plan and Flowsheets were reviewed for Patient #3. Nurse #2 revealed there was a Care Plan for Trauma/Injury Risk; however, it was not specific to falls.
The Fall Risk Factors and Interventions on the Nursing Flowsheet included: bed in low position; wheels locked, call light in reach; and ID band on.
Review of the Nursing Flowsheet Data from 4/26/11 indicated Safety Interventions included alarm(s) activated and audible.
Nurse #2 explained all beds have alarms, and they are set at a specific sensitivity level; light, moderate, or heavy. She added it was not evident which setting was indicated for Patient #3.
Review of the electronic Nurses Notes dated 4/26/11 at 0920 indicated staff heard a thud and found the patient on the floor crawling on her/his hands and knees from bathroom door to her/his bed. Stated she/he fell on floor and landed on bottom. No injury. Neuro team notified.
Review of a Resident ' s Neurology Note dated 4/27/11 did not address the patient's unwitnessed fall on 4/26/11.

3. Patient #4 was admitted to the hospital on 4/17/11and discharged on 4/27/11. The Nursing Admission Skin Assessment dated 4/17/11 identified an excoriation, redness and slight skin breakdown over coccyx. The Braden Risk Assessment for Skin on admission was 16 (if 18 or less activate Pressure Ulcer, Risk guidelines - per facility documentation).
A Care Plan was initiated for this patient and incorporated pressure reduction techniques, per Care Plan guidelines. According to Nurse #3 on 4/27/11 at approximately 3:00PM, this would include repositioning.
Review of the electronic record with Nurse #3 revealed on 4/21/11, the following entries appeared: 0844 - Up in chair; 1200 - Up in chair, pillow support chair cushion in place; and 1500 - Up in chair, pillow support, legs elevated. Nurse #3 agreed the entries would indicate the patient did not have a position change from the chair during that time.
Further review of the electronic record denoted the Care Plan for Pressure Ulcer Risk established a goal of resolution; however, the record documented " unable to achieve outcome at discharge. "