HospitalInspections.org

Based on document review and interview, the facility failed to provide nursing supervision for mobility and wound care in 1 of 10 (Patient #2) medical records reviewed.

Findings Include:

1. Review of policy titled: Skin Breakdown Prevention last reviewed 7/2018, indicated patients with a Braden Score of 14 or less will be turned every 2 hours, observe for blanched reddened areas and patient cannot remain in a sitting position for more than 1 hour.

2. Review of Patient 2's medical record indicated the Integumentary Assessment completed by nursing on 11/11/19 at 4:14 pm (admission) indicated that patient had a scab on left knee; small stage 2 area to the left lateral leg; small reddened area in left groin; left upper extremity from elbow down is a reddish purple; and "the coccyx is slightly reddened". The medical record lacked documentation that nursing notified the MD of areas potentially needing treatment orders. Nursing documentation indicated the patient's Braden Score was 14 or less on 11/17/19, 11/21/19 and 11/22/19. The medical record lacked documentation of turning patient every 2 hours or repositioning on those dates. Nursing documentation indicated assessment of left lateral thigh wound on 11/13/19, 11/14/19 and 11/17/19 and lacked documentation of status of this area on other dates of stay.

3. Interview on 01/15/20 with P51 (Vice-President of Nursing) at 3:40 pm confirmed MR documentation as indicated above.