HospitalInspections.org

Based on record review, policy review and staff interview it was determined the Registered Nurse (RN) failed to supervise and evaluate nursing care related to patient reassessment, repositioning, and hygiene needs for 4 (# 3, #5, #6, #7) of 10 sampled patients. This practice does not ensure patient goals are met and may lead to a prolonged hospital stay.


Findings include:

1. Patient #3 was admitted to the facility on 2/8/12. The medical record was reviewed for provision of basic nursing care for hygiene. Review of the documentation revealed no evidence that hygiene care was provided on 2/17, 2/19, 3/5, 3/11, and 3/18/12. The dietician who was present during the record review at approximately 2:00 p.m. on 5/16/12 confirmed the findings.

2. The facility's policy "Assessment/Reassessment-Interdisciplinary Patient", #H-PC 04-09, last revised 11/10, required that the patients be assessed each shift and that an RN perform an assessment at leave every 24 hours.

Patient #3 was admitted to the facility on 2/8/12. Review of the nursing documentation revealed there was no RN assessment on 2/19, 2/16, 2/17, 3/1, 3/7, 3/13, and 3/30/12.

Patient #7 was admitted to the facility on 5/10/12. Review of the nursing assessments revealed there was no RN assessment on 5/12/12 and 5/15/12.

Patient #5's nursing documentation revealed there was no RN assessment on 5/9/12.

3. The facility's policy "Prevention of Skin Breakdown", #H-WC 01-001, last revised 6/12, required that patients at risk for skin breakdown be repositioned every 2 hours.

Patient #6 was admitted with a stage 3 pressure ulcer of the sacrum and was at high risk for further development. Review of nursing documentation revealed there was no documentation of repositioning on the following dates and times:
5/12/12 from 2:03 a.m. until 5:30 a.m. and from 2:00 p.m. until 5:36 p.m.
5/15/12 from 4:05 p.m. until 7:11 p.m.

Patient #5 was admitted to the facility on 5/2/12 with pressure ulcers of the right heel, sacrum and mid back. Review of the medical record revealed lack of documentation of repositioning on the following dates and times:
5/10/12 from 12:00 noon until 5:24 p.m.
5/16/12 from 8:14 a.m. until 12:08 p.m.

The dietician was present during review of medical records for patients #5, #6, and #7 on 5/17/12 from 12:30 p.m. until 3:30 p.m. She confirmed the above findings.