HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt #1) clinical records reviewed for pressure ulcer prevention and care, the Hospital failed to ensure that Pt #1 was turned and repositioned every 2 hours to prevent pressure ulcers, as ordered.

Findings include:

1. On 9/14/2020, the Hospital's Clinical Guidelines for Pressure Injury (release date 06/2019) was reviewed and indicated " ...The skin and wound assessment is conducted by the RN (Registered Nurse) on admission and each shift ...Each patient should have an individualized plan of care created around the identified risk level ...Considerations for patients requiring every 1 to 2 hours turn and repositioning: patient unable to turn and reposition self, poor nutrition, multiple wounds ...poor cognition ..."

2. -Pt #1's face sheet, dated 7/13/2020, noted Pt #1 was admitted on 7/13/2020 with the following diagnoses: "Respiratory failure; acute respiratory failure; functional quadriplegia (paralysis caused by an illness or injury that results in the partial or total loss of all four limbs and torso); pressure ulcer of right heel (Stage 3); Pressure ulcer of sacral region (Stage 3); unspecified severe protein-calorie malnutrition; encephalopathy(brain disease that alters brain function); epilepsy (seizure disorder) tachycardia (increased heart rate), dysphagia (difficult swallowing) myoneural disorder (neuromuscular disorder characterized by skeletal muscle weakness), anemia ..."

-MD #2 admitting orders, dated 7/13/2020, indicated, "Reposition every 2 hours..."

-Pt #1's admission Braden [risk of developing a pressure ulcer) assessment, dated 7/13/2020 indicated, " ...Braden scale -13 - moderate risk ..."

-Pt #1's wound assessment note, dated 7/14/2020, indicated, "Pressure injury (Sacrum) - Wound onset type (present on admission) - Stage 3 - Wound length (2 cm/0.8 in), wound width (0.5 cm/0.2 cm), wound depth (0 cm), necrotic tissue (none)"

-Pt #1's wound weekly wound assessments from 7/21/2020 - 8/16/2020 indicated that the Stage 3 pressure injury of the Sacrum was "healed, resolved wound."

-Pt #1's nursing assessment note, dated 8/17/2020 indicated, "Pressure injury Sacrum - stage 3, wound length (2.5 cm/1in), wound width (1 cm/0.4 in), wound depth (0.1 cm)"

-Pt #1's Wound Physician's (MD #1) note, dated 8/17/2020, indicated, " ...Wound care service was placed on consultation today as Pt #1 seems to have reopened a small pressure injury of the sacrum with which she was initially admitted ...Back - no active wounds, sacrum - stage III pressure injury of sacrum, measures 2.5 x 1 x 0.1, buttocks and groin - no active wounds, right and left lower extremity - no active wounds. Impression - small stage III pressure injury of sacrum ..."

-Pt #1's repositioning notes (dated 7/13/2020 through 8/17/2020) were reviewed and indicated that every 2 hour turns were not completed on the following dates/times:
-7/25/2020 - supine position at 5:32 AM and to left side 9:29 AM (almost 4 hours later)
-7/26/2020 - elevated 30 degrees at 5:33 AM and to right side at 9:05 AM (approximately 3 hours and 32 minutes later)
-7/28/2020 - to left side at 4:00 PM and to right side at 8:00 PM (4 hours later)
-8/1/2020 - to supine position 12:27 PM and to left side at 3:20 PM (2 hours and 53 min later)
-8/8/2020 - to left side at 10:00 AM and to right side at 2:00 PM (4 hours later)
-8/9/2020 - to supine position at 6:00 AM and to right side at 9:05 AM (3 hours and 5 minutes later)
-8/14/2020 - to right side at 2:00 AM and to right side at 8:05 AM (6 hours and 5 minutes later)

3. On 9/14/2020 at 1:30 PM, an interview was conducted with the Wound Care Doctor (MD #1). MD #1 stated that he assessed Pt #1 on the day of her discharge (8/17/2020). MD #1 stated that Pt #1's healed stage 3 pressure ulcer on her sacrum reopened that day of discharge. MD #1 stated that patients with pressure ulcers should be turned every two hours.