HospitalInspections.org

Based on review of reported grievances, policy review, staff interview and review of other hospital documents, it was determined that for 2 of 3 (33%) patients in the sample (Patient #'s 1 and 8) who had filed grievances, the hospital failed to provide the complainants with written notification of the hospital's investigative findings and decision. Findings include:

The hospital policy entitled "Customer Complaint Grievance Policy" stated, "A concern deemed a grievance will receive a written response...The Vice President for Mission and Ministry (or designee) is responsible for a written response to the patient/complainant of either acknowledgement of receipt or resolution of the grievance within 7 days...In its resolution of the grievance...provide the patient with written notice of it [sic] decision that contains the name of the hospital contact person...steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion within 21 days..."

1. Patient #1
a. Complaints filed on 5/13 and 5/15/09:
Review of the "Complaint Report" revealed that formal complaints were filed by two members of Patient #1's family on 5/13 (verbal) and 5/15/09 (written). Review of the occurrence report file revealed that an initial letter acknowledging the receipt of the 5/13/09 complaint was sent on 5/14/09. The letter revealed that a full investigation would be conducted by the hospital. Review of hospital documents revealed no evidence to support that written notice was sent to Patient #1's family regarding the outcome of their two formal complaints.

b. Complaint filed on 12/1/09:
Review of the "Grievance Report" revealed Patient #1's family filed a formal complaint with the hospital on 12/1/09. Review of hospital documents revealed no evidence to support that written notice was sent to the complainant regarding the results of the hospital's investigation.

During an interview on 1/8/10 at 12:45 PM, Patient Advocate #1 confirmed that the concerns related to Patient #1's care were handled as formal grievances, not complaints.

During an interview on 1/14/10 at 3:50 PM with the Vice President for Mission and Ministry and the Vice President of Patient Services and Chief Nursing Officer, the Vice President for Mission and Ministry confirmed that final written notice had not been sent to the complainants as per hospital policy.

2. Patient #8
a. Complaints filed on 6/1 and 6/7/09:
Review of the "Grievance Report" revealed Patient #8 filed formal complaints with the hospital on 6/1 (verbal) and 6/7/09 (written). Review of the occurrence report file revealed that an initial letter, acknowledging the receipt of the complainant's concerns, was sent to the complainant on 6/2/09. The letter revealed that a full investigation would be conducted. Review of hospital documents revealed no evidence to support that written notice was sent to the complainant following the hospital's investigation.

During an interview on 1/15/10 at 9:23 AM, Patient Advocate #1 confirmed that final written notice had not been sent to Patient #8 as per hospital policy.

I. Based on medical record review, clinical practice guideline review, job description review and staff interview, it was determined that for 2 of 6 (33%) patients in the sample (Patient #'s 1 and 2), identified as being at risk for skin breakdown, the registered nurse (RN) failed to ensure that patients' skin care needs were met. In addition, failure to ensure that skin care interventions were implemented resulted in the development of pressure ulcers for Patient #1. Findings include:

The hospital document entitled "Competency-Based Job Description...Senior Team Leader" stated, "...evaluates the effectiveness of Nursing care...Keeps Patient Care Activity Record to accurately reflect patients current needs...Develops, initiates, monitors and evaluates the plan of care for each patient in her assigned zone in collaboration with the other staff members on her team...Complies with established hospital policies..."

Review of the hospital document entitled "Standard of Clinical Practice...Skin Integrity, Impaired, Actual, Potential..." stated, "...Patient will not develop skin impairment...Implement Impaired Skin Integrity Care Plan..."

Review of the hospital document entitled "Nursing General Clinical Practice...Prevention and Treatment of Pressure Ulcers" stated, "Skin Care Protocol for Prevention of Pressure Ulcers...Turn and position every two hours in bed...Intact Blister...request Treatment Order from Physician...Consult Wound Care...pressure sores present as...redness...proper measurements...request Treatment Order from Physician...Assess skin for impairment and document daily and according to nursing flow sheet..."

Review of the "Pressure Risk Scale" tool utilized by staff to determine a patient's risk for the development of skin breakdown stated, "...Use score to determine need for...skin care intervention...For a score of 16 or less, implement Impaired Skin Integrity Care Plan..."

A. Patient #1
Review of the 11/24/09 "Interdisciplinary Admission Assessment" completed by RN C at 6:00 PM, revealed Patient #1's skin had no open wounds at the time of admission.

Review of "Pressure Risk Scale" documentation revealed Patient #1 was assessed to be at moderate risk for skin breakdown with a score of 14. Since the score was less than 16, a skin integrity care plan should have been implemented.

Review of the "Interdisciplinary Plan of Care" revealed no skin integrity care plan as required.

Review of 11/27/09 "Potential or Actual Loss of Skin Integrity" documentation for 2:00 AM, revealed the presence of two wounds - Wound #1 - located on the sacrum and Wound #2 - located on the left heel.

Review of "Physician's Orders" and "Patient Progress Notes" revealed no evidence to support that nursing staff notified Physician A of Patient #1's heel blister and sacral pressure ulcer as required.

Review of patient care flowsheet "Turning Program" documentation revealed staff failed to turn and reposition Patient #1 every two hours on the following dates and times:

11/25/09 - 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM

11/26 and 11/27/09 - 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM

11/28/09 - 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM

11/29/09 - 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM

11/30/09 - 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM

12/1/09 - 12:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM and 2:00 PM

Interviews with the Director of Quality Management and Performance Improvement on 1/15/10 at 9:45 AM and 1:10 PM confirmed these findings. The Director reported that it is the Senior Team Leader's responsibility to ensure that all assigned tasks are completed as delegated by either the Team Leader or in the absence of Team Leader, the Director.

During interviews with wound ostomy continence nurse (WOCN) #1 on 1/14/10 at 3:13 PM and 1/15/10 at 12:45 PM, WOCN #1 reported that RN C approached her on 11/30/09 and asked her to assess Patient #1's sacrum. WOCN #1 reported that Patient #1 presented at that time with a hospital acquired deep tissue injury on the sacrum. WOCN #1 reported that she did not evaluate Patient #1's heel and had not received a wound care referral prior to the 11/30/09 intervention.

B. Patient #2
Review of the 12/31/09 "Interdisciplinary Plan of Care" revealed an intervention to turn Patient #2 every two hours.

Review of "Pressure Risk Scale" documentation revealed Patient #2 was assessed to be at high risk for skin breakdown with a score of 10.

Review of patient care flowsheet "Turning Program" documentation revealed staff failed to turn and reposition Patient #2 every two hours according to the plan of care on the following dates and times:

1/6/10 - 10:00 PM
1/8 and 1/10/10 - 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM

On 1/14/10 at 2:53 PM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #2's chart and confirmed that documentation failed to provide evidence that staff turned and repositioned Patient #2 every two hours according to the plan of care.

II. Based on medical record review, review of clinical practice guidelines, job description review and staff interview, it was determined that the RNs failed to ensure that vital signs were assessed for 4 of 7 (57%) patients in the sample (Patient #'s 1, 2, 5 and 7) reviewed for vital sign monitoring. Findings include:

The hospital document entitled "Competency-Based Job Description...Senior Team Leader" stated, "...monitors and evaluates the plan of care for each patient in her assigned zone...Complies with established hospital policies..."

Review of the hospital document entitled "Patient Care Services Nursing...Guidelines for Nursing Routines: Scope of Care" stated, "...Obtain patient's vital signs (Temp, Pulse, B/P [blood pressure]) and document on graphic sheet...Q (every) 8 hours for unmonitored patients...Review orders, complete flowsheet..."

A. Patient #1
Review of "Discharge Instruction" documentation revealed Patient #1 was discharged to home on 12/1/09 at 3:00 PM. Review of the "Vital Signs...Record" revealed no vital sign assessment for the 7:00 AM - 3:00 PM shift on 12/1/09, the day of discharge. "Vital Signs...Record" documentation dated 12/1/09, revealed Patient #1's vital signs were last assessed on the 11:00 PM - 7:00 AM shift.

Review of an entry on the "Patient Progress Notes" by Social Worker A revealed Patient #1 was to be discharged to home with follow-up care to be provided by the home health agency (HHA) chosen by Patient #1's family.

Review of the HHA's clinical record revealed an admission assessment was conducted at Patient #1's place of residence on 12/2/09 at 11:30 AM. At the time of assessment, RN B documented that she was unable to obtain Patient #1's blood pressure. RN B notified Physician A and Patient #1 was transported by paramedics to an acute care hospital for evaluation and treatment.

On 1/11/10 at 2:00 PM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #1's medical record and confirmed that vital signs had not been assessed on the 7:00 AM - 3:00 PM shift for 12/1/09. The Director confirmed that Patient #1's vital signs were last assessed on 12/1/09 at 4:00 AM and that the expectation was that vital signs should be done as ordered or every shift.

B. Patient #2
Review of the "Vital Signs...Record" revealed no vital sign assessments for the 7:00 AM - 3:00 PM shift on 1/6, 1/9, and 1/11/10.

On 1/14/10 at 2:15 PM, Surveyor A, the Director of Quality Management and Performance Improvement and Senior Director A reviewed Patient #2's medical record and confirmed that vital signs were not assessed every shift. Senior Director A confirmed that on the seventh floor, vital signs were expected to be done at least every shift.

C. Patient #5
"Physician's Orders" dated 1/6/10 at 5:00 AM, included orders for vital signs every four hours.

Review of the "Vital Signs...Record" revealed no vital sign assessments for the following dates/times:

1/6/10 - 6:00 PM
1/7/10 - 4:00 AM, 8:00 AM, 12:00 PM and 6:00 PM
1/8/10 - 12:00 AM, 4:00 AM, 10:00 AM and 6:00 PM
1/9/10 - 12:00 AM, 8:00 AM and 6:00 PM
1/10/10 - 12:00 AM, 4:00 AM, 10:00 AM and 2:00 PM
1/11/10 - 12:00 AM, 4:00 AM, 10:00 AM, 12:00 PM and 6:00 PM
1/12/10 - 12:00 AM, 4:00 AM, 10:00 AM and 6:00 PM
1/13/10 - 12:00 AM, 4:00 AM, 10:00 AM, 6:00 PM and 10:00 PM
1/14/10 - 12:00 AM, 4:00 AM and 10:00 AM

On 1/14/10 at 1:56 PM, Surveyor A, the Director of Quality Management and Performance Improvement and Senior Director A reviewed Patient #5's medical record and confirmed that vital signs were not assessed every four hours as per physician's orders.

D. Patient #7
"Physician's Orders" dated 1/9 (no identified year) at 1:40 AM, included orders for vital signs every shift.

Review of the "Vital Signs...Record" revealed no vital sign assessment for the 7:00 AM - 3:00 PM shift on 1/13/10.

On 1/14/10 at 2:15 PM, Surveyor A, the Director of Quality Management and Performance Improvement and Senior Director A reviewed Patient #7's chart and confirmed this finding.

Based on medical record review, clinical practice guideline review and staff interview, it was determined that for 2 of 6 (33%) patients in the sample (Patient #'s 1 and 3), identified as being at risk for skin breakdown and/or skin was identified as impaired, staff failed to implement a skin integrity care plan. Findings include:

The hospital document entitled "Competency-Based Job Description...Senior Team Leader" stated, "...Adheres to hospital nursing practice standards...Updates and initiates Care Plans..."

Review of the hospital document entitled "Standard of Clinical Practice...Skin Integrity, Impaired, Actual, Potential..." stated, "...Patient will not develop skin impairment...Implement Impaired Skin Integrity Care Plan..."

Review of the "Pressure Risk Scale" tool utilized by staff to determine a patient's risk for the development of skin breakdown stated, "...Use score to determine need for...skin care intervention...For a score of 16 or less, implement Impaired Skin Integrity Care Plan..."

1. Patient #1
Review of "Pressure Risk Scale" documentation revealed Patient #1 was assessed to be at moderate risk for skin breakdown with a score of 14. Since the score was less than 16, a skin integrity care plan should have been implemented.

Review of the "Interdisciplinary Plan of Care" revealed no skin integrity care plan as required.

Review of 11/27/09 "Potential or Actual Loss of Skin Integrity" documentation for 2:00 AM, revealed the presence of two wounds - Wound #1 - located on the sacrum and Wound #2 - located on the left heel.

On 1/8/10 at 2:35 PM, Surveyor A and Clinical Review Analyst A reviewed Patient #1's medical record and confirmed that staff failed to initiate a skin integrity care plan for Patient #1.

2. Patient #3
Review of the "Pressure Risk Scale" documentation revealed Patient #3 was assessed to be at high risk for skin breakdown with a score of 10-12.

Review of the "Interdisciplinary Plan of Care" revealed staff failed to implement a skin integrity care plan when Patient #3's "Pressure Risk Scale" was assessed to be less than 16.

On 1/14/10 at 10:22 AM, Surveyor A and Senior Director A reviewed Patient #3's medical record and confirmed that staff failed to initiate a skin integrity care plan for Patient #3. Senior Director A reported that based on the patient's pressure risk score, a care plan for skin integrity should have been implemented.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to ensure that medical record entries for 6 of 7 (86%) patients in the sample (Patient #'s 1, 2, 3, 4, 5 and 7), were legible, dated and timed. Findings include:

The hospital document entitled "Medical Staff Bylaws" stated, "...attending physician shall be responsible for the preparation of a legible, complete medical record...All orders for patient care shall be in writing with both date and time...verbal orders...practitioner should sign telephone orders within 48 hours..."

1. Patient #1 (admitted 5/9/09)
Review of "Patient Progress Notes" revealed several illegible entries made by Physician A. Progress notes dated 5/11, 5/12, 5/13, 11/26 and 11/30/09 could not be read in their entirety.

On 1/15/10 at 10:30 AM, the Director of Quality Management and Performance Improvement, Clinical Review Analyst A and Team Leader A unsuccessfully attempted to read the progress notes identified above. On 1/15/10 at 11:12 AM, seventh floor unit staff, directly responsible for accessing and reading medical record information, were asked by Surveyor A and the Director of Quality Management and Performance Improvement, to assist in deciphering several of Physician A's entries. Attempts made by Unit Clerk A, registered nurse (RN) A and Social Worker A were only partially successful.

Interview with the Director of Quality Management and Performance Improvement on 1/15/09 at 11:25 AM, confirmed that Physician A's medical record entries were not always legible as required by medical staff bylaws.

2. Patient #2 (admitted 12/31/09)
a. "Physician's Orders" documentation failed to include the following information:

12/31/09 at 1:20 PM - (Verbal order) No date or time of authentication

1/6, 1/11, 1/12 and 1/13/10 - No time of entry

b. "Patient Progress Notes" documentation failed to include the following information:

1/7, 1/8, 1/11, 1/12 and 1/13/10 (two entries) - No time of entry

c. Review of a vascular surgery "Consultation Report" included entries by Physician B (Resident) and Physician C (Attending physician). The individual entries were not timed or dated.

On 1/14/10 at 2:35 PM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #2's medical record and confirmed that professional staff did not always include the date, time and year of entries into the legal record. The Director reported that both consulting physicians should have timed and dated their individual assessments.

3. Patient #3 (admitted 1/6/10)
a. "Physician's Orders" documentation failed to include the following information:

1/9/10 - (Verbal order) No time of entry for the receipt of orders; No date or time of authentication

On 1/14/10 at 10:22 AM, Surveyor A and Senior Director A reviewed Patient #3's medical record and confirmed the above findings.

4. Patient #4 (admitted 1/8/10)
a. "Physician's Orders" documentation failed to include the following information:

1/11 - No identified year or time of entry
1/12 at 5:20 AM and 10:00 AM - No identified year
Verbal order obtained at 8:00 PM - No date
1/13/10 - No time of entry
1/13 at 12:00 PM and 6:00 PM - No identified year

b. "Patient Progress Notes" documentation failed to include the following information:

1/10/08 at 10:20 AM - Inaccurate year of entry
1/10, 1/12 and 1/13 - No identified year or time of entry
1/11, 1/12 and 1/13/10 (three entries) - No time of entry
1/12 at 5:25 AM and 1/14 at 5:50 AM - No identified year

On 1/14/10 at 10:35 AM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #4's medical record and confirmed that professional staff did not always include the date, time and year of entries into the legal record. The Director confirmed that the 2008 year of entry for 1/10 was inaccurate.

5. Patient #5 (admitted 1/6/10)
a. "Physician's Orders" documentation failed to include the following information:

1/7 at 8:30 AM (Verbal order), 1/13 at 9:45 AM and 1/14 at 10:40 AM - No identified year
1/12 - No identified year or time of entry

b. "Patient Progress Notes" documentation failed to include the following information:

1/13 and 1/14/10 (two entries) - No time of entry

On 1/14/10 at 1:56 PM, Surveyor A and Senior Director A reviewed Patient #5's medical record and confirmed the above findings.

6. Patient #7 (admitted 1/9/10)
a. "Physician's Orders" documentation failed to include the following information:

1/9 at 1:40 AM - No identified year

On 1/14/10 at 1:56 PM, Surveyor A and Senior Director A reviewed Patient #7's medical record and confirmed the above finding.

I. Based on medical record review, review of clinical practice guidelines and staff interview, it was determined that staff failed to document vital signs for 4 of 7 (57%) patients in the sample (Patient #'s 1, 2, 5 and 7) reviewed for vital sign documentation. Findings include:

Review of the hospital document entitled "Patient Care Services Nursing...Guidelines for Nursing Routines: Scope of Care" stated, "...Obtain patient's vital signs (Temp, Pulse, B/P [blood pressure]) and document on graphic sheet...Q (every) 8 hours for unmonitored patients...Review orders, complete flowsheet..."

A. Patient #1
Review of "Discharge Instruction" documentation revealed Patient #1 was discharged to home on 12/1/09 at 3:00 PM. Review of the "Vital Signs...Record" revealed no vital sign documentation for the 7:00 AM - 3:00 PM shift on 12/1/09, the day of discharge.

On 1/11/10 at 2:00 PM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #1's medical record and confirmed that vital signs had not been documented as completed on the 7:00 AM - 3:00 PM shift for 12/1/09. The Director confirmed that Patient #1's vital signs were last documented as completed on 12/1/09 at 4:00 AM and that the expectation was that vital signs should be done as ordered or every shift.

B. Patient #2
Review of the "Vital Signs...Record" revealed no vital sign documentation for the 7:00 AM - 3:00 PM shift on 1/6, 1/9, and 1/11/10.

On 1/14/10 at 2:15 PM, Surveyor A, the Director of Quality Management and Performance Improvement and Senior Director A reviewed Patient #2's medical record and confirmed that vital signs were not documented as completed every shift. Senior Director A confirmed that on the seventh floor, vital signs were expected to be done at least every shift.

C. Patient #5
"Physician's Orders" dated 1/6/10 at 5:00 AM, included orders for vital signs every four hours.

Review of the "Vital Signs...Record" revealed no vital sign documentation for the following dates/times:

1/6/10 - 6:00 PM
1/7/10 - 4:00 AM, 8:00 AM, 12:00 PM and 6:00 PM
1/8/10 - 12:00 AM, 4:00 AM, 10:00 AM and 6:00 PM
1/9/10 - 12:00 AM, 8:00 AM and 6:00 PM
1/10/10 - 12:00 AM, 4:00 AM, 10:00 AM and 2:00 PM
1/11/10 - 12:00 AM, 4:00 AM, 10:00 AM, 12:00 PM and 6:00 PM
1/12/10 - 12:00 AM, 4:00 AM, 10:00 AM and 6:00 PM
1/13/10 - 12:00 AM, 4:00 AM, 10:00 AM, 6:00 PM and 10:00 PM
1/14/10 - 12:00 AM, 4:00 AM and 10:00 AM

On 1/14/10 at 1:56 PM, Surveyor A, the Director of Quality Management and Performance Improvement and Senior Director A reviewed Patient #5's medical record and confirmed that vital signs were not documented as completed every four hours as per physician's orders.

D. Patient #7
"Physician's Orders" dated 1/9 (no identified year) at 1:40 AM, included orders for vital signs every shift.

Review of the "Vital Signs...Record" revealed no vital sign documentation for the 7:00 AM - 3:00 PM shift on 1/13/10.

On 1/14/10 at 2:15 PM, Surveyor A, the Director of Quality Management and Performance Improvement and Senior Director A reviewed Patient #7's chart and confirmed this finding.

II. Based on medical record review, clinical practice guidelines review and staff interview, it was determined that for 3 of 5 (60%) patients in the sample (Patient #'s 1, 2 and 3), identified as being at risk for skin breakdown, staff failed to document turning and repositioning every two hours. Findings include:

Review of the hospital document entitled "Nursing General Clinical Practice...Prevention and Treatment of Pressure Ulcers" stated, "Skin Care Protocol for Prevention of Pressure Ulcers...Turn and position every two hours in bed...Assess skin for impairment and document daily and according to nursing flow sheet..."

Review of the "Pressure Risk Scale" tool utilized by staff to determine a patient's risk for the development of skin breakdown stated, "...Use score to determine need for...skin care intervention...For a score of 16 or less, implement Impaired Skin Integrity Care Plan..."

A. Patient #1
Review of "Pressure Risk Scale" documentation revealed Patient #1 was assessed to be at moderate risk for skin breakdown with a score of 14.

Review of patient care flowsheet "Turning Program" documentation revealed staff failed to turn and reposition Patient #1 every two hours on the following dates and times:

11/25/09 - 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM

11/26 and 11/27/09 - 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM

11/28/09 - 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM

11/29/09 - 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM

11/30/09 - 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM

12/1/09 - 12:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM and 2:00 PM

On 1/8/10 at 2:35 PM, Surveyor A and Clinical Review Analyst A reviewed Patient #1's medical record and confirmed that Patient #1 should have been turned and repositioned at least every two hours while hospitalized. Clinical Review Analyst A confirmed that documentation failed to provide evidence that staff turned and repositioned Patient #1 every two hours.

B. Patient #2
Review of the 12/31/09 "Interdisciplinary Plan of Care" revealed an intervention to turn Patient #2 every two hours.

Review of "Pressure Risk Scale" documentation revealed Patient #2 was assessed to be at high risk for skin breakdown with a score of 10.

Review of patient care flowsheet "Turning Program" documentation revealed staff failed to turn and reposition Patient #2 every two hours according to the plan of care on the following dates and times:

1/6/10 - 10:00 PM
1/8 and 1/10/10 - 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM

On 1/14/10 at 2:53 PM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #2's chart and confirmed that documentation failed to provide evidence that staff turned and repositioned Patient #2 every two hours according to the plan of care.

C. Patient #3
Review of "Pressure Risk Scale" documentation revealed Patient #3 was assessed to be at high risk for skin breakdown with a score of 10-12.

Review of patient care flowsheet "Turning Program" documentation revealed staff failed to turn and reposition Patient #3 every two hours on the following dates and times:

1/12/10 - 8:00 PM and 10:00 PM
1/9/10 - 8:00 AM, 10:00 AM, 12:00 PM and 2:00 PM

On 1/14/10 at 10:30 AM, Surveyor A and the Director of Quality Management and Performance Improvement reviewed Patient #3's chart and confirmed that documentation failed to provide evidence that staff turned and repositioned Patient #3 every two hours.