HospitalInspections.org

Based on review of documentation and interview with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed. Physician orders for repositioning Patient #1 were not followed by nursing staff while the patient was on complete bed rest.

Findings were:

Patient #1 underwent surgery on 2/6/12, and the ICU physician's order was for the patient to be on complete bed rest following the surgery. The order included that the patient should be turned from side to back to side every 2 hours in order to maintain skin integrity. According to the nursing flow sheet, Patient #1 was not turned as ordered by the physician on 2/7/12 and 2/8/12. For example, on 2/7/12 the patient was placed on the right side at noon, and then every 2 hours until 8 pm, was documented as continuing to lie on the right side. On 2/8/12, Patient #1 was noted to be lying on the left side between the hours of 4 am to 7:30 am; there is no documentation of the patient's position at the 10 am entry. Again, on 2/13/2012, Patient #1 was placed on bed rest while in ICU. At 2:30 pm, the patient was on the left side and remained on the left side until 8 pm, according to the documentation. On 2/14/12, the patient was documented on the left side at noon, 2 pm, and 4 pm.

These findings were acknowledged by Staff #2, Quality Improvement Coordinator, during a review of Patient #1's electronic medical record the afternoon of 6/5/12.