HospitalInspections.org

Based on review of medical records, policy and procedures and staff interviews, it was determined that facility staff failed to reposition patients per protocol contributing to the development of pressure ulcers (localized damage to the skin as a result of usually long-term pressure) for one patient (P) (P#1) of four sampled patients.

Findings include:

A review of P#1's medical record revealed P#1 was admitted to the facility on 12/02/2024 with a diagnosis of Cerebrovascular accident (CVA-medical term for a stroke).

A review of P#1's Braden Scale Chart" for Predicting Pressure Sore Risk" (scale used to predict the probability of developing a pressure sore) revealed a score of 7-12. (score less than 9 indicates a patient was as severe risk for developing pressure sores and score of 10-12 indicates that a patient was at high risk for the development of pressure sores)

A review of the 'Daily Cares and Safety Flowsheet' revealed that P#1 was turned on the following dates with times:
12-2-24 1000
12-3-24 0243, 2000
12-4-24 2000
12-5-24 0000, 0400, 0700, 2200
12-6-24 0000, 0200, 0400, 0800, 1100, 1600, 2000
12-7-24 0000, 0400, 0800, 1100, 1600, 2300
12-8-24 0800, 1000, 1200, 1400, 1600, 1841, 1935
12-9-24 0800, 1000, 1200, 1400, 1600, 1800, 2114
12-10-24 0800, 1000, 1200, 1400, 1916
12-11-24 1317, 2000
12-12-24 2000
12-13-24 0800, 2000
12-14-24 0726, 0812, 1105, 1302, 2043
12-15-24 0717, 2051
12-16-24 0715, 1919
12-17-24 0715, 1900
12-18-24 0715
12-19-24 0720
12-20-24 2000
12-21-24 0000, 0400, 0952, 1915
12-22-24 0950
12-23-24 0932, 1915
12-24-24 2000
12-25-24 1953
12-26-24 0748, 2003
12-27-24 0800, 2330
12-28-24 0800, 1200, 1600
12-29-24 0800, 1200, 1600
12-30-24 0800, 1200, 1600, 2000
12-31-24 0100, 0800, 1200, 1600, 2300
1-1-25 0731
1-2-25 0000, 1117, 2030
1-3-25 0733, 2149
1-4-25 0742, 1945
1-5-25 0656
1-6-25 0800, 1200, 1600
1-7-25 0800, 1200, 1600, 1915, 2000
1-8-25 0000, 0800, 1200, 1800, 1915
1-9-25 0000, 0400, 0600, 0700, 1100, 1300, 1500, 1700, 2043
1-10-25 0800, 2000, 2222
1-11-25 0230, 0800, 1924, 2130
1-12-25 0713, 2243
1-13-25 0800, 2032
1-14-25 0000, 0200, 0400, 0651, 0800
1-15-25 2000
1-16-25 0800, 2000
1-17-25 0800, 1901
1-18-25 0800, 1901
1-19-25 0739, 1901
1-20-25 0715, 1915
1-21-25 0745, 1937, 1944
1-22-25 0715, 1923
1-23-25 0715, 2025
1-24-25 0800, 1923
1-25-25 1747, 1921
1-26-25 1712, 1953
1-27-25 2011
1-28-25 0800, 1000, 1206, 1400, 1600, 1800, 2232
1-29-25 0700, 0900, 1100, 1300, 1500, 1755, 2000, 2200
1-30-25 0000, 0200, 0400, 0600, 0755, 2051
1-31-25 0714, 2000
2-1-25 0801, 1910, 2000
2-2-25 0000, 0200, 0600, 0753, 2240
2-3-25 0000, 0200, 0600, 0810, 2200
2-4-25 0200, 0400, 0807, 2031
2-5-25 0720, 1916
2-6-25 none
2-7-25 none
2-8-25 0934, 2108
2-9-25 0714, 0904, 1010, 1431, 1805
2-10-25 1243
2-11-25 none
2-12-25 0951, 2023
2-13-25 1915
2-14-25 1628, 2200
2-15-25 none
2-16-25 1504
2-17-25 1626, 2000
2-18-25 0757, 2000
2-19-25 1032, 2026
2-20-25 1153, 1416, 1745, 2200
2-21-25 0001, 0400, 0600
2-22-25 1900, 2100, 2300
2-23-25 0300, 0500, 0700, 0825, 1041, 1419, 1545, 2045, 2330
2-24-25 0240, 0400, 0630, 0815, 1028, 1505, 1815
2-25-25 0852, 1028, 1525, 1801, 2000, 2200
2-26-25 0001, 0201, 0400, 0620, 0830, 1045, 1230, 1412, 1645, 1839, 1934, 2134, 2230, 2359
2-27-25 0200, 0400, 0610, 2030
2-28-25 0000, 2241
3-1-25 1900, 2101, 2300
3-2-25 0100, 0300, 0500, 0800, 1000, 1240, 1400, 1600, 1614, 1800


A further review of P#1 medical record's 'Wound Flow Sheet' revealed that on:

12-9-24 a new wound was assessed on the buttocks measuring 5.5 cm x 1.8 cm and 0.2 cm in depth. A wound care consult was placed, and the wound was treated with Fiber/Silver-Silicone adhering foam.
1-7-25 a skin tear was assessed on P#1's left side of her vagina. There was no drainage and it was treated with zinc oxide paste by wound management.
2-26-25 a pressure injury was assessed on P#1's right ear. No drainage noted. The wound measured .9 cm x 0.4 cm. It was cleansed and left open to air by wound management.


An interview was conducted in the conference room on 3/4/26 at 9:20 a.m. with Nursing Director (ND) AA. ND AA revealed she had not rounded on P#1. ND AA further explained that the standard of care for any patient with a Braden Score of seven (7)-12 was turning every two (2) hours. ND AA stated that typically the nurse transferring the patient from the floor notified the patient's family that the patient has been transferred to another floor.


An interview was conducted in the conference room on 3/4/26 at 9:27 a.m. with Nurse Manager (NM) CC. According to NM CC, she made daily rounds on patients and speaks with family members. NM CC recalled that P#1's family members voiced concerns about the care provided to P#1 in the neuro intensive care unit. The family members felt that the staff were giving up on P#1 too quickly regarding her condition from her stroke. NM CC also met with P#1's sister who was concerned about the importance of turning the patient. NM CC stated P#1 was repositioned every two (2) hours and received proper nutrition. NM CC never saw fluid coming from P#1's ear. NM CC explained that it was not standard procedure to notify family when patients were moved to a lower level of care. NM CC stated the physician usually notify' s the family, not the nursing staff. NM CC explained that the physician usually discussed code status and other plans of care during that time. If patients were not being turned, it was documented in the chart. NM CC stated that the facility uses 'Evidence Based Clinical Documentation' (EBCD). NM CC explained that with EBCD, basic standard of care activities such as baths, oral hygiene and repositioning were not charted.


An interview was conducted in the conference room on 3/4/26 at 9:37 a.m. with NM BB. NM BB stated P#1's sisters were her (P#1) point of contact and they were concerned about her care plan and about the brain death testing. NM BB did not recall fluid coming from P#1's ear. NM BB stated that the primary nurse was responsible for calling the patient's family when a patient was being moved to another floor. She explained that patients were turned every two hours, assessed for nutrition, and placed wedges and padding between legs and under the heels. Staff follow EBCD charting guidelines.


An interview was conducted in the conference room on 3/4/25 at 10:10 a.m. with Vice President of Quality, Risk Management, and Patient Safety (VP) FF. She revealed that Evidence Based Clinical Documentation (EBCD) was initiated to decrease the amount of documentation that the staff are required to do. VF FF also revealed it was created to allow the staff to have more contact with the patient and spend less time documenting. VP FF explained that the corporate leadership developed guidelines for how to document basic standards of care that are given, for example oral care, turning patients every two hours, and deep vein thrombosis prophylaxis. VP FF stated it was expected that if staff did not complete the patient care task, then they would document that it not being done.


A telephone interview was conducted on 3/4/26 at 10:45 a.m. with Patient Care Technician (PCT) GG. PCT GG stated she turns patient every two hours. She stated she sets a reminder on her phone. PCT GG did not know if there was a place in the medical record to document patient turns. PCT GG denied any communication with P#1's family.


A telephone interview was conducted on 3/4/26 at 10:48 a.m. with Registered Nurse (RN) HH. RN HH stated that P#1's family member called daily for updates on her condition. RN HH stated that she turned P#1 every two hours when she was her patient and documented under the "skin" tab in the medical record. RN HH did not remember P#1's family complaining about drainage coming from her ear. RN HH recalled being told in orientation that patient turning needed to be documented once a day.


A telephone interview was conducted on 3/4/26 at 10:55 am with RN II. RN II stated that when she took care of P#1 there were no concerns from her family members and did not see drainage coming from P#1's ears. RN II explained that staff was responsible for notifying the patients family when patients were transferred off of a unit. RN II stated that the physician also usually communicates to the family. RN II explained that a Braden Score was documented once a day. s RN II explained that since it is understood that patients were turned every two hours, turning was documented once per shift. RN II stated that sometimes she documents more than one time.


A telephone interview was conducted on 3/4/2025 at 11:20 a.m. with RN JJ. RN JJ stated she remembers patient and had her for one shift. RN JJ stated that she turned her patient's every two hours, puts wedges between their legs and pads under their heels to prevent pressure wounds. RN JJ stated she tried to document every time she turned her patients. RN JJ called family members when her assigned patients were transferred to another unit.


A review of the facility's "Critical Care Mobility Protocol" revealed that for Level One Modified Mobility patients are to be repositioned every two hours with active and passive range of motion with turns .


A review of the facility's policy titled "Pressure Injury Prevention-Adults," Policy# 14728558, last revised 02/2024, revealed that the purpose of this policy is to:
1. Outline expectations for pressure injury risk assessment and skin assessment.
2. Provide evidence-based guidelines for pressure injury prevention based on a patient's individual risk factors.
3. Establish documentation requirements related to pressure injury prevention.
Adult patients 18 years of age or older will be assessed for pressure injury risk using the Braden II Scale. A score of less than or equal to 18 is considered at risk.
POLICY:
A. Pressure Injury Risk and Skin Assessment:
1. All adult patients will be assessed for pressure injury risk using the Braden II Scale at the following intervals:
a. upon admission or bed hold in ED
b. each shift
c. following a decline in medical condition
d. upon transfer to a different nursing unit
2. A full head-to-toe skin assessment must be performed and documented on all adult patients at the following intervals:
a. upon admission or bed hold in ED
b. each shift
c. following a decline in medical condition
d. upon transfer to a different nursing unit
3. The clinician will use visual, touch and palpation techniques when assessing the skin to differentiate temperature and tissue differences.
4. Particular focus will be given to the skin over bony prominences including the sacrum, heels, hips, elbows, occiput and any areas under medical devices including but not limited to: condom catheters, CPAP/BIPAP masks, oxygen tubing, ET tubes, NG or NJ tubes, lower extremity compression stockings/devices, removable splints/ braces, any device securement apparatus.
5. Assess for signs of skin maceration in areas exposed to moisture as well as skin folds and creases.
6. Use the following techniques to aid in assessment of darker skin tones:
a. Establish baseline skin tone in an area not frequently exposed to ultraviolet radiation.
b. Use adequate lighting; the best lighting includes ambient or natural sources. Appropriate lighting also includes halogen lamp or flashlight (eg., cell phone, or pen light).
c. Thoroughly cleanse area to be assessed. Remove bodily fluids and any skin care products.
d. Compare skin area to be assessed to surrounding unaffected area.
e. Compare same area to be assessed to opposite laterality when possible.
7. Preventive dressings should be lifted each shift to assess the skin underneath the dressing for breakdown.
8. Any skin alterations or wounds found upon skin assessments will be documented in the electronic medical record and appropriate action taken.
B. Pressure Injury Prevention Measures:
1. Interventions to prevent pressure injury (or further skin injury) will be applied based on the Braden risk score and each precipitating risk factor identified. (See attachment #1)
2. Braden subscale scores and additional risk factors (i.e. use of pressors, history of a previous pressure injury) should be considered when identifying interventions to be implemented, even if the overall score indicates a patient may not be at risk.
3. The measures taken to reduce pressure injury risk for each patient will be documented in the electronic medical record.
4. Patient and/or family members will be provided with pressure injury prevention education.