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SINAI-GRACE HOSPITAL
NURSING CARE PLAN
Tag No.: A0396
Based on document review and interview review the facility failed to follow nursing care plans for one (#1) of four patients resulting in the development of a pressure wound.
On 10/21/2020 at 1330 during the document review of patient #1's medical record it was revealed patient #1 developed a pressure wound located in the sacral area. The patient was admitted to the hospital via the emergency room on 7/27/2020 with "altered mental status." The initial nursing admission assessment completed on 7/28/2020 revealed the patient had a stage 3 lateral left lower leg wound. Documentation for turning and repositioning of the patient included : 7/28/2020 at 1500, 7/29/2020 at 1400 and 1700, 7/31/2020 0100 and 2100, 8/1/2020 at 0600, 0700, and 2100, 8/2/2020 at 0300, 1600, 2000, and 2100. On 8/3/2020 documentation for a stage 2 sacral wound was discovered in the medical chart.
On 10/21/2020 at 1345 an interview occurred with the Chief Nursing Officer, Staff B. Staff B was queried if turning and repositioning of the patient should be included in the documentation of nursing care. Staff B stated that the expectation is for staff to document repositioning of the patient every two hours minimally. Staff B was then asked if documentation had been completed every two hours for patient #1 for repositioning. Staff B stated, "No."
On 10/21/2020 at 1350 a review occurred of the policy titled, "Skin and Wound Care," policy number 2 PC 5200, dated effective date of April 10, 2018. According to the policy it states," III. K. Any pressure injury that develops 24 hours after admission to the hospital or is not documented as present on admission within 24 hours is defined as a hospital-acquired pressure injury (HAPI)....M. Patients are repositioned minimally every 2 hours. Able patients are taught to shift their body weight while in bed and chair sitting. EMR (electronic medical record) documentation of repositioning occurs in the Plan of Care under Comments. Additionally, repositioning may be documented in the activity section of the EMR."