HospitalInspections.org

Based on interview and record review the hospital failed to implement care plan interventions for two of 30 sampled patients (Patient 1 & Patient 12) when:

1. Staff failed to document required repositioning of Patient 1 from 10/5/24 2038-10/6/24 2038 (24 hour period)

2. Staff failed to document implementation of Patient 12's Sequential Compression Device (SCD-a mechanical device that helps prevent blood clots and improve circulation in the legs) until over 13 hours after the order was placed by the Physician

These failures had the potential for Patient 1's pressure injury (is localized damage to the skin and underlying soft tissue, caused by prolonged or intense pressure, shear, or friction forces) to worsen, and had the potential for Patient 12 to develop blood clots in the lower legs.

Findings:

1. During a review of Patient 1's "Wound Care Instruction" dated 9/25/24, instruction indicated, Patient 1 had multiple pressure injuries. Instruction indicated, "Location #1 Coccyx [the last bone at the bottom of the spine] . . .OFF LOAD [a method of preventing and treating pressure injury/ulcers by reducing or removing weight from a wounded area by repositioning] AT all times".

During a review of Patient 1's Plan of Care dated 9/25/24, Plan of Care indicated, "Skin-Care . . . Turn Q 2 [every 2] Hours".

During a review of Patient 1's Flowsheet titled "Reposition Patient Every 2 Hrs" dated 9/25/24-10/8/24 flowsheet indicated, no documentation Patient 1 was turned after 10/5/24 at 1838.

During a review of Patient 1's "Physical Therapy Evaluation" dated 10/4/24 Evaluation indicated, "Overall Bed Mobility Ability: Moderate assistance, Maximum Assistance". Evaluation indicated, "How much difficulty does the pt [patient] have now -Turning over in bed: A lot (Max/Mod Assist) [maximum to moderate assistance required]".

During an interview on 11/6/24, at 10:15 a.m., with Chief Nursing Officer (CNO) CNO stated, there was no documentation Patient 1 was turned every 2 hours on 10/6/24 or after.

During an interview on 11/7/24, at 9:11 a.m., with the Accreditation & Regulatory Coordinator (ARC) , the ARC stated, there was no documentation that Patient 1 refused to be turned at any time on 10/6/24 or after.

During a review of the hospitals policy and procedure (P&P) titled, "Skin Assessment, Pressure Injury-Identification, Prevention and Treatment" dated 2024, the P&P indicated, ". Turn patient and document positioning at least every two hours".

2. During a review of Patient 12's Care Plan dated 11/6/24, Care Plan indicated, "Mobility impaired. . .outcome optimize mobility. . .Intervention VTE Mechanical Device [SCDs]".

During a review of Patient 12's Order titled, "VTE Mechanical Device" dated, 11/6/24 at 19:14, order indicated, Patient 12's Physician made an order for the use of "Sequential Stockings [SCDs}".

During a review of Patient 12's "Care Assessment" flowsheet dated 11/7/24, flowsheet indicated, the SCD device was not applied to Patient 12 until 11/7/24 at 08:58 (over 13 hours after ordered by Physician).

During an interview on 11/7/24, at 10:16 a.m., with the ARC, the ARC stated, the first documentation of the SCD being placed on Patient 12 was on 11/7/24 at 0858. ARC stated, the order for the SCD was placed on 11/6/24 at 1914. The ARC confirmed, there was no documentation that Patient 12 refused the SCD.

During a review of the hospitals procedure titled "VTE Prevention" undated, procedure indicated, "VTE Mechanical devices should be on continually except when ambulating or bathing".