HospitalInspections.org

Based on findings from medical record review, facility document review and interview, in 4 of 11 medical records (MRs) reviewed of patients at risk of pressure ulcer development (Patients A, B, C, D), nursing staff did not consistently document turning and repositioning and elevation of heels (while in bed).

Findings include:

--The hospital's policy and procedure (P&P) titled "Skin and Wound Care," last revised 11/2013, described the following procedures: Nursing staff assess a patient's risk for pressure ulcer development using the Braden Scale For Pressure Sore Risk (Braden Scale) which requires scoring of patient risk factors. For patients at risk for pressure ulcer development (i.e., Braden score < 19) nursing staff implement skin care guidelines that correspond to Braden subscale scores. The frequency of turning and repositioning of patients in bed is based on the Braden Scale mobility subscore. For a patient with mobility subscore of 3 or 4, nursing staff should turn and reposition a minimum of every 4 hours; mobility subscore of 1 or 2, or an existing pressure ulcer, nursing staff should turn and reposition every 2 hours. Heels should be elevated at all times while in bed and if pillows do not maintain heel elevation, physical/occupational therapy should be consulted for a rigid or waffle boot. Nursing staff should document position changes, including the specific position the patient is placed in, along with heel elevation.

--Per review of the MRs of Patients A, B, C and D, although nursing staff assessed the patients as being at risk for pressure ulcer development, documentation of turning and positioning and heel elevation in the MRs is incomplete.

Examples include:

*Review of Patient A's MR revealed he was admitted on 1/6/15 at 1613 with diagnoses of acute encephalopathy and electrolyte imbalances due to dehydration and malnutrition. Patient A's history included a left below the knee amputation (BKA). Throughout Patient A's hospitalization, nursing staff assessed the patient's Braden Scale score as 10 to 15 (high to moderate risk) with mobility subscores of 1 and 2 (completely immobile to limited mobility).

On 1/11/15 at 0900, Patient A's Braden score was 12 with mobility subscore of 1. From 0600 on 1/11/15 to 0800 on 1/12/15, there is no documentation that nursing staff turned and repositioned the patient every 2 hours and elevated his right heel while in bed.

On 1/12/15 at 1100, Patient A's Braden score was 15 with mobility subscore of 2. At 1253, Wound Ostomy Nurse (WON) #1 ordered a waffle boot to be placed on Patient A's right foot. However, from 0500 to 1800 on 1/13/15, there is no documentation by nursing staff indicating the waffle boot was applied or that the patient's right heel was elevated.

On 1/15/15 at 0100, Patient A's Braden score was 12 with mobility subscore of 2. From 1858 on 1/15/15 to 0600 on 1/16/15, there is no documentation indicating nursing staff turned and repositioned Patient A every 2 hours or elevated the patient's right heel off the bed


*Review of Patient B's open MR on 3/31/15 at 1000 revealed he was a quadriplegic patient admitted on 3/27/15 for colostomy and gastrointestinal issues. He had a preexisting pressure ulcer on admission. On 3/28/15, the patient's Braden Scale score was 10 (high risk).

From 1400 to 0000 on 3/28/15, with the exception of 2000 when nursing staff documented that the patient was repositioned and heels elevated, there is no documentation indicating that nursing staff turned and repositioned Patient B at least every 2 hours or elevated his heels.

*Review of Patient C's open MR on 3/30/15 revealed he was admitted to the neurosurgical stepdown unit on 3/21/15 with diagnosis of urosepsis.

On 3/23/15 at 2000 Patient C's Braden Scale score was 15; mobility subscale was 2. From 2200 on 3/23/15 to 0800 on 3/24/15, there is no documentation indicating nursing staff turned and repositioned the patient every 2 hours or that his heels were elevated off the bed.

*Review of Patient D's open MR on 3/30/15 at 1100 revealed she was admitted on 3/27/15 at 16:46 with diagnosis of pneumothorax after a fall.

On 3/28/15 at 0140, Patient D's Braden Scale score was 16; mobility sub scale was 3 (slightly limited). From 3/28/15 at 0030 to 3/29/15 at 12:00, there is no documentation indicating that nursing staff turned and repositioned the patient at least every 4 hours or elevated the patient's heels while she was in bed.

--During interview of the hospital's Director of Patient Safety on 3/31/15 at 2:30 pm, he/she acknowledged that documentation in the MR of turning and repositioning and heel elevation by nursing staff was incomplete.