HospitalInspections.org

Based on record review and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care related to Activities of Daily Living for one (#1) of seven records reviewed. This practice does not ensure patient goals are met.

Findings include:

Review of the record for patient #1 revealed the patient was admitted on 4/3/11. Nursing admission data revealed the patient had a history of dementia, was confused, and needed complete assistance with ADL's (Activities of Daily Living). Further review of the nursing admission assessment revealed the patient had a stage II pressure ulcer on the coccyx.

Review of the patient's plan of care revealed impaired skin integrity was identified on the plan of care and initiated on admission. Nursing interventions revealed the patient would be turned and repositioned every two hours. Review of the daily nursing shift assessments and the nursing notes revealed the patient was not assisted to turn and reposition every two hours from admission to discharge on 4/9/11 with the exception of 4/07/11 from 7:00 a.m. to 7:00 p.m.

On 5/10/11 at 3:45 p.m. an interview with the Chief Nursing Officer confirmed the above findings.