HospitalInspections.org

Based on record review and staff interview it was determined the facility failed to ensure an adequate number of nursing personnel was available to ensure the needs of the patients were met for 2 (#1, #5) of 5 patients sampled. This practice does not ensure the patients goals are achieved.

Findings include:

1. Interview with a staff nurse on 3/08/10 at approximately 11:45 a.m. revealed the staff member stated s/he felt there was not enough Patient Care Technicians (PCT) to assist with the turning and repositioning of patients. Interview with a PCT on 3/08/10 at approximately 12:15 p.m. revealed the technician stated s/he was not always able to turn the patients every two hours.

2. Patient #1's nursing admission assessment, dated 10/22/08 at 5:30 p.m., and the wound care nurse assessment, dated 10/23/08, revealed the patient had erythema to the left buttock and stage II pressure ulcer to the sacrum. Review of the nursing admission assessment revealed the patient was unable to turn independently in bed.
Review of the patient's plan of care revealed the patient was to be turned every two hours. Review of the physician progress notes revealed on 3/25/09 the physician noted the sacral wound to be worse. The note stated to turn more frequently and try to keep the patient off his/her back. Review of the turn and repositioning documentation revealed several dates the patient was not turned every two hours and was kept supine. The documentation noted:
On 3/27/09 at 10:00 a.m. the patient was turned to the supine position and remained in the supine position until 4:00 p.m. when the patient was turned to the right side.
On 3/30/09 at 5:50 a.m. the patient was turned to the supine position and remained in the supine position until 10:00 a.m. when the patient was turned to the right side.
On 3/30/09 at 4:00 p.m. the patient was turned to the supine position and remained in the supine position until 8:34 p.m. when the patient was turned to the left side.
On 4/3/09 at 12:00 p.m. the patient was turned to the supine position and remained in the supine position until 4:12 p.m. when the patient was turned to the right side.

3. Patient #5 was admitted on 2/22/10. Nursing documentation revealed the patient had a pressure ulcer to the coccyx, right lateral ankle and left ankle. Review of the turn and repositioning documentation revealed several dates the patient was not turned every two hours as per the plan of care.
On 2/24/10 at 6:00 a.m. the patient was turned to the supine position and remained in the supine position until 10:00 a.m. when the patient was turned to the left side.
On 2/24/10 at 4:00 p.m. the patient was turned to the right side and remained on the right side until 8:00 p.m. when the patient was turned to the left side.
On 3/01/10 at 12:00 a.m. the patient was turned to the left side and remained on the left side until 6:00 a.m. when the patient was turned to the left side.

4. Review of the ADL's documentation revealed several days that Patient #1 was not provided care to include peri care, bathing, urinary catheter, mouth care, skin care and changing of linens. The following days patient #1 was not provided ADL care: 11/06/08, 11/10/08, 11/13/08 and 11/15/08.
Interview with the nurse manager on 3/08/10 at approximately 3:30 p.m. confirmed the above findings.

Based on record review and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 2 (#1, #5) of 5 patients sampled. This practice does not ensure the patients needs are being met.

Findings include:

1. Patient #1's nursing admission assessment, dated 10/22/08 at 5:30 p.m., and the wound care nurse assessment, dated 10/23/08, revealed the patient had erythema to the left buttock and stage 2 pressure ulcer to the sacrum measuring 0.7 cm (centimeters) in length by 3 cm wide. Review of the nursing admission assessment revealed the patient was unable to turn independently in bed and required assistance for ADL's (Activities of Daily Living).

Review of the patient's plan of care revealed the patient had impaired skin integrity and was to be turned every two hours. Review of the physician progress notes revealed on 3/25/09 the physician noted the sacral wound to be worse. The note stated to increase the pressure prevention measures, turn more frequently and try to keep the patient off his/her back. Review of the turn and repositioning documentation revealed several dates the patient was not turned every two hours and was kept supine. The documentation noted:
On 3/27/09 at 10:00 a.m. the patient was turned to the supine position and remained in the supine position until 4:00 p.m. when the patient was turned to the right side.
On 3/30/09 at 5:50 a.m. the patient was turned to the supine position and remained in the supine position until 10:00 a.m. when the patient was turned to the right side.
On 3/30/09 at 4:00 p.m. the patient was turned to the supine position and remained in the supine position until 8:34 p.m. when the patient was turned to the left side.
On 4/3/09 at 12:00 p.m. the patient was turned to the supine position and remained in the supine position until 4:12 p.m. when the patient was turned to the right side.

2. Patient #5 was admitted on 2/22/10. Nursing documentation revealed the patient had a pressure ulcer to the coccyx, right lateral ankle and left ankle. Review of the turn and repositioning documentation revealed several dates the patient was not turned every two hours as per the plan of care.
On 2/24/10 at 6:00 a.m. the patient was turned to the supine position and remained in the supine position until 10:00 a.m. when the patient was turned to the left side.
On 2/24/10 at 4:00 p.m. the patient was turned to the right side and remained on the right side until 8:00 p.m. when the patient was turned to the left side.
On 3/01/10 at 12:00 a.m. the patient was turned to the left side and remained on the left side until 6:00 a.m. when the patient was turned to the left side.

3. Interview with a staff nurse on 3/08/10 at approximately 11:45 a.m. revealed the staff member stated s/he felt there was not enough Patient Care Technicians (PCT) to assist with the turning and repositioning of patients. Interview with a PCT on 3/08/10 at approximately 12:15 p.m. revealed the technician stated s/he was not always able to turn the patients every two hours.

4. Review of the ADL's documentation revealed several days that Patient #1 was not provided care to include peri care, bathing, urinary catheter, mouth care, skin care and changing of linens. The following days patient #1 was not provided ADL care: 11/06/08, 11/10/08, 11/13/08 and 11/15/08.
Interview with the nurse manager on 3/08/10 at approximately 3:30 p.m. confirmed the above findings.