HospitalInspections.org

Based on document review and interview, nursing failed to ensure policies/standards were followed for turning and repositioning patients for 2 of 10 patients (patients #4 and 9), failed to limit the length of time in chair for 1 of 10 patients (patient #4) and failed to complete an incident report for patients developing a hospital acquired pressure ulcer for 2 of 10 patients (patients #1 and #4).

Findings include:

1. Facility policy titled "Adult Skin and Wound Care" last approved 11/2013 states on page 5 under protocol: "F. All skin injuries that are hospital acquired (....pressure ulcers....) are reported via an incident report....". Page 9 states: "e. Limit the time an individual spends seated in a chair if patient is at risk for pressure ulcer development or if pressure ulcer is present." Page 11 states for patients with a stage III or IV wound: "a. Rescue skin by relieving all pressure to the injured area. Turn/reposition frequently......"

2. Review of patient #1 medical record indicated the following:
(A) He/she was admitted on 10/25/15. The medical record indicated there were no pressure areas on admission.
(B) Nurses notes dated 11/7/15 indicated that a pressure ulcer described as a deep tissue injury and not stageable had developed on the patient's nose.

3. Review of patient #4 medical record for stay #1 indicated the following:
(A) He/she was admitted to the facility on 9/29/15. The medical record indicated there were no pressure areas on admission.
(B) Nurses notes dated 10/5/15 at midnight indicated that a pressure ulcer had developed on sacral/coccyx area. The area was a stage II wound.

4. Review of patient #4 medical record for stay #2 indicated the following:
(A) He/she was admitted to the facility on 10/26/15. He/she was documented as having a stage II pressure area to the sacral area on admission nursing assessment and the wound was classified as a stage III during wound care consult dated 10/27/15.
(B) The medical record indicated the patient was up in a chair from 1100-1600 hours on 11/9/15 and lacked documentation of pressure relieving actions taken while up in chair from 1100 hours to 1600 hours on 11/9/15.

5. Review of patient #4 medical record for stay #3 indicated the following:
(A) He/she was admitted to the facility on 11/28/15. He/she was documented as having an unstageable sacral/coccyx wound on admission.
(B) The medical record lacked documentation that the patient was turned from 2130 hours on 11/28/15 to 1000 hours on 11/29/15. He/she was documented as being on his/her back during that time.
(C) The medical record lacked documentation that the patient was turned from 0400 hours to 1800 hours on 12/7/15. He/she was documented as remaining on his/her left side during that time.
(D) The medical record lacked documentation that the patient was turned to a specific side from 0200 hours on 12/8/15 to 1600 hours 12/10/15. The documentation stated "assist" with no left, right, or back documented.
(E) The medical record indicated the patient was up in chair from 1200 hours to 1600 hours on 12/8/15 with no documentation of pressure relieving measures used during this time.

6. Review of patient #4 medical record for stay #5 indicated the following:
(A) He/she was admitted on 12/16/15. He/she was documented as having an unstageable sacral/coccyx on admission.
(B) The medical record lacked documentation that the patient was turned at 1700 hours on 12/17/15 and at 0900 hours on 12/18/15.

7. Review of patient #9 medical record lacked documentation that the patient was turned from midnight to 0800 hours on 2/5/16 and from 0200 hours to 0600 hours on 2/6/16.

8. Staff member #3 (Clinical Informatics Manager) verified the medical record information for patients #1 and 4 beginning at 12:30 p.m. on 2/10/16.

9. Staff member #4 (RN) verified medical record information for patient #9 beginning at 5:10 p.m. on 2/10/16.

10. Staff member #2 (Accreditation Specialist) indicated in interview at 3:30 p.m. on 2/10/16 that there were no incident reports completed for pressure areas on patients #1 and #4.

11. Staff member #4 (Registered Nurse [RN]) indicated in interview at 4:50 p.m. on 2/10/16 that patients are turned every 2 hours if not more often.

12. Staff member #5 (Shift Coordinator) indicated in interview at 4:55 p.m. on 2/10/16 that patients are to be turned at a minimum of every 2 hours.

13. Staff member #6 (Director Critical Care) indicated in interview at 4:58 p.m. on 2/10/16 that patients are to be turned at a minimum of every 2 hours.