HospitalInspections.org

Based on document review and interview, nursing services failed to turn/reposition patient every 2 hours per policy for 1 of 10 patients (Patient 6).

Findings include:

1. Facility policy titled, Pressure Injury Assessment, Prevention, And Treatment Including Braden Scale/Braden Q - Adult And Pediatric, last revised 4/2022, indicated all patients will have a full skin assessment upon admission. Document full skin assessment within 4 hours in the integumentary section of the patient's electronic medical record. The Braden assessment will be done on admission and every shift thereafter. Use an appropriate mattress surface for those patients at risk of skin breakdown. Reposition and assess for moisture every two hours, or more frequently, for Braden score of 9 to 17.

2. Review of patient 6's medical record indicated patient's Braden score was between 9-17. Medical record lacked documentation of patient turning/repositioning every 2 hours as required from 3/7/24 through discharge on 3/18/24. Patient's MR indicated he/she was turned/repositioned the following days and number of times per 24 hours:
a. 3/07/24 - patient turned/repositioned 1 times.
b. 3/08/24 - patient turned/repositioned 0 times.
c. 3/09/24 - patient turned/repositioned 3 times.
d. 3/10/24 - patient turned/repositioned 5 times.
e. 3/11/24 - patient turned/repositioned 2 times.
f. 3/12/24 - patient turned/repositioned 3 times.
g. 3/13/24 - patient turned/repositioned 2 times.
h. 3/14/24 - patient turned/repositioned 4 times.
i. 3/15/24 - patient turned/repositioned 0 times.
j. 3/16/24 - patient turned/repositioned 2 times.
k. 3/17/24 - patient turned/repositioned 2 times.

3. In interview on 4/22/24 at approximately 4:17 pm to 4:20 pm, A3 (Quality Manager) confirmed P6's MR lacked documentation of patient turned/repositioned every 2 hours as required from 3/7/24 through 3/18/24.