HospitalInspections.org

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure nursing care was provided for one (1) of ten (10) sampled patients (Patient #9). The facility failed to ensure Patient #9 was repositioned every two (2) hours as evidenced by no documentation the patient was repositioned every two hours. The facility also failed to ensure nurses provided care to promote optimal healing for one (1) of ten (10) sampled patients (Patient #4) as evidenced by observations of Registered Nurse (RN) #1 cleaning four (4) wounds with the same piece of gauze.

The findings include:

1. Review of the facility's policy titled, "Wound Prevention Policy" #W05-N, dated 06/10/08, revealed patients that were bed bound or with limited activity should be repositioned every two (2) hours.

Review of the facility's policy titled, "Skin Care, Assessment and Maintenance Of Policy # S02-N", Revised 01/01/11, revealed bedfast patients should be turned every two (2) hours unless contraindicated by physician's order.

Record review revealed the facility admitted Patient #9 on 12/31/11 with diagnoses which included Pneumonia, Septic Shock and Chronic Renal Failure. Continued record review revealed Patient #9 was bed bound, had numerous wounds upon admission and was assessed as being at risk for skin break down.

Review of the 24 Hour Patient Record and Plan of Care for patient #9 revealed the patient was to be repositioned every two (2) hours and as needed (prn). Further review of the 24 Hour Patient Record and Plan of Care revealed no documented evidence the patient was repositioned on the following days: 01/01/12-from 8:00 AM to 12:00 PM, from 12:00 PM to 3:00 PM, from 3:00 PM to 6:00 PM and from 6:00 PM to 9:00 PM; 01/21/12- from 3:00 PM until 8:00 PM; 01/23/12- from 2:00 PM until 7:00 PM; 01/26/12- from 7:00 AM until 10:00 AM, 02/06/12- from 8:00 AM to 7:00 PM; and 03/26/12- from 7:00 AM to 11:00 AM.

Interview, on 04/10/12 at 9:30 AM, with the Director of Quality Management revealed patients were to be repositioned every two (2) hours and as needed (prn). She stated technicians, nurses, therapy staff and other staff turned patients and turns were to be documented on the 24 Hour Patient Record and Plan of Care, either in the section for rounds or in the Nurses Notes.

Interview, on 04/10/12 at 5:55 PM, with the Chief Nursing Officer revealed patients should be turned every two (2) hours according to the facility's policy. She stated turns were to be documented on the 24 Hour Patient Record and Plan of Care, and could be documented in the hourly rounds section or could be written in the Nurses Notes.

2. Record Review revealed Patient #4 was admitted on 04/06/12 with diagnoses which included Motor Vehicle Accident resulting in Pelvic Fractures and numerous other fractures and wounds. Observation during the admission skin/wound assessment, on 04/06/12 at 2:00 PM, RN #1 was observed cleaning four small wounds and the skin surrounding the wounds using the same piece of 4 x 4 gauze.

Interview, on 04/10/12 at 9:30 AM, with the Director of Quality Management revealed RN #1 should have used one (1) 4 x 4 gauze for each wound, and cleaned the wound from clean to dirty. She stated one (1) 4 x 4 would not be appropriate for cleaning the four (4) wounds and surrounding areas.

Interview, on 04/10/12 at 3:44 PM, with the RN #1 revealed she would typically clean each wound with a different 4 x 4 gauze and she should not have cleaned them with the same 4 x 4 gauze.

Interview, on 04/06/12 at 6:30 PM, with the Chief Nursing Officer revealed RN #1 should have used a separate 4 x 4 gauze for each wound and she should have cleaned the wounds from clean to dirty.