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Based on observation, interview, and record review, the hospital failed to ensure licensed nurses adhered to the hospital's policies and procedures when:

1. Three of 30 sampled patients (Pt 2, Pt 4, and Pt 5) did not have their pain reassessed after the administration of pain medications in accordance with the hospitals policy and procedure (P&P) titled "Pain Management".

These failures had the potential to result in Pt 2, Pt 4 and Pt 5 to have inadequate pain management and could negatively affect the physical, emotional, and psychosocial well-being of the patients.

2. One of two sampled patients (Pt 5) had a fever of 101.1 (degrees Fahrenheit-[F-a scale for measuring temperature; normal: 97-99 F, fever: greater than or equal to 100.4 F]), 15 minutes after the completion of a blood transfusion and was not reported to the physician and no interventions were implemented.

This failure resulted in Pt 5's fever after the blood transfusion to not be reported to the physician and no interventions were implemented and had the potential to develop into an adverse reaction i which could be minimal to life threatening.

3. Licensed Nurse (LNs) did not document Pt 2's heels were elevated off the bed on 11/5/24, 11/6/24, 11/7/24 and 11/8/24 to prevent a pressure injury (damage to skin and underlying tissue caused by prolonged pressure) for one of 30 sampled patients (Pt 2) in accordance with the hospitals P&P titled "Pressure Injury Risk Assessment and Prevention".

This failure resulted in Pt 2 developing a stage 2 pressure injury (partial thickness loss of skin, appearing as a shallow open sore or blister, where the skin has broken open, exposing the dermis layer, usually representing as a red or pink wound bed without any deeper tissue damage like muscle or bone exposure) to the right heel on 11/7/24.

Findings:

1.During a review of Pt 2's "History & Physical (H&P)", dated 11/17/24, the H&P indicated, Pt 2 was admitted from 11/4/24 to 11/15/24 for post-surgical care after right hip surgery.

During a concurrent interview and record review on 11/22/24 at 10:55 a.m. with the Clinical Coordinator (CC) and Nurse Manager (NM) 3, Pt 2's "Pain Screening/Assessment Scale Flowsheet (PSASF)", dated 11/4/24 to 11/21/24 was reviewed. The PSASF indicated, Pt 2 was assessed for pain using the Face, Legs, Activity, Cry and Consolability (FLACC scale- a behavioral pain assessment scale used to evaluate pain severity in children who are unable to communicate pain, 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 worst pain) scale. The PSAF indicated, on 11/9/24 at 5:32 a.m., Pt 2 was assessed for pain, had a FLACC score of 3 on a 0-10-point scale, no pain interventions were done and there was no reassessment of pain. On 11/9/24 at 8 a.m., Pt 2 was assessed for pain, had a FLACC score of 2, on a 0-10-point scale, no pain interventions were done and there was no reassessment of pain. On 11/9/24 at 11:41 a.m., Pt 2 was assessed for pain, had a FLACC score of 4, on a 0-10-point scale, and was administered ibuprofen (an anti-inflammatory drug used to relieve pain, fever, and inflammation) and there was no reassessment of pain. On 11/9/24 at 4:06 p.m.,
Pt 2 was assessed for pain, had FLACC score of 5, on a 0-10-point scale, no pain interventions were done and there was no reassessment of pain. On 11/13/24 at 2:30 p.m., Pt 2 was assessed for pain, had FLACC score of 6, on a 0-10-point scale was administered ibuprofen and was reassessed for pain One hour and 45 minutes later at 4:15 p.m. The CC validated there was no documentation of non-pharmacological interventions done, pain medications were not administered, and pain was not reassessed. The CC stated pain medications should have been administered. The CC stated the LNs could have implemented interventions such as, repositioning, distraction, or should have notified the physician promptly. The CC stated the expectation for the LN's were to reassess pain an hour after pain medication was administered and it was not done. The CC stated Pt 2's pain was not controlled. The CC stated it was important to keep the patient at a comfortable pain level since the patient could not communicate. NM 3 stated the LN's did not provide relief for Pt 2's pain.

During a concurrent interview and record review on 11/25/24 at 10:30 a.m. with Registered Nurse (RN) 5, Pt 2's "Pain assessment Flowsheet (PAF)" dated 11/9/24 and "Daily Cares / Safety Flowsheet (DSF)", dated 11/9/24 were reviewed. RN 5 stated she was the nurse assigned to Pt 2 on 11/9/24 from 7 a.m. to 7:30 p.m. RN 5 stated on 11/9/24 at 8 a.m. Pt 2 had a pain level of 2 on the FLACC scale. RN 5 stated no intervention were done because she was busy and should have reassessed Pt 2's pain and documented the pain assessment. RN 5 stated on 11/9/24 at 11:41 a.m. Pt 2 had a pain score of 4 on the FLACC scale, and Pt 2 was administered ibuprofen 350 milligrams (mg-unit of measurement) at 11:41 a.m. RN 5 stated she did not reassess Pt 2's pain. RN 5 stated the policy was to reassess pain within an hour after interventions and she should have reassessed and documented pain assessments after the intervention. RN 5 stated Pt 2's vital signs (VS-measurements of the body's basic function, such as breathing, heart rate (HR), respiration rate (RR) and temperature) on 11/9/24 at 4:06 p.m. were HR of 101 (normal heart rate 60-100), RR of 17 (normal respiratory rate 12-18) and pain score of 5 on the FLACC scale. RN 5 stated Pt 2 was repositioned, the DSF did not indicate Pt 2 was repositioned and she did not document the pain intervention. RN 5 stated she did not follow the facility's policy to document the interventions that were done. RN 5 stated Pt 2's VS on 11/9/24 at 5 p.m. were a HR of 116, RR of 34, RN 5 stated she believed the changes in VS from 4:06 p.m. to 5 p.m. had to do with the pain experienced by Pt 2 and the failure to provide intervention. RN 5 stated she tried to reach the provider twice and received a pain medication order on 11/9/24 at 5:38 p.m. for Hydrocodone-acetaminophen (potent drug for moderate-to-severe pain control in patients) Hydrocodone-acetaminophen was administered at 5:55 p.m. RN 5 stated interventions were not provided promptly enough. RN 5 stated, " ...I should have called whoever is over the hospitalist, or the on-call doctor ...". RN 5 stated there was no documentation of reassessment of pain after administering the medication at 5:55 p.m. RN 5 stated the importance of reassessing the patients' pain was to see if the intervention worked and Pt 2's pain could have increased. RN 5 stated, " ...Our goal as nurses is to treat the patient and help with their pain ...".

During a concurrent interview and record review on 11/25/24 at 11:23 a.m. with RN 4, Pt 2's PAF dated 11/13/24 was reviewed. RN 4 stated she was assigned to Pt 2 on 11/13/24 from 7 a.m. to 7:30 p.m. RN 4 stated on 11/13/24 at 2:30 p.m. Pt 2's FLACC score was 6 and Pt 2 was administered ibuprofen 350 mg at 2:30 p.m. and reassessment of pain was completed at 4:15 p.m. RN 4 stated reassessment should have been done within an hour but was not done according to her documentation. RN 4 stated the importance of reassessing the patient's pain was to determine if Pt 2's pain was managed by the intervention and to know if it was successful or not. RN 4 stated Pt 2 could have unmanageable pain due to reassessing the patient's pain late.


During a concurrent interview and record review on 11/25/24 at 10:48 a.m. with RN 8, Pt 5's "History and Physical (H&P-a doctor's initial assessment of a patient by asking about their medical history and physically examining them)," dated 11/14/24 was reviewed. RN 8 stated the H&P indicated, "Chief Complaint: Acute anemia [a rapid decrease in red blood cells], suspected hemolytic uremic syndrome [a serious disease that affects the kidneys and blood clotting system] ...vomiting and diarrhea for four days ...Patient was admitted to acute care floor. Morning labs were drawn and showed significant drop in hemoglobin [a protein in red blood cells that carries oxygen from the lungs to the body's tissues and organs-normal levels:10-15.5] from 11 to 5 ..."

During a concurrent interview and record review on 11/25/24 at 10:48 a.m. with RN 8, Pt 5's "Physician Orders (PO)," Pt 5's "Medication Administration Record (MAR-all medications administered to a patient)," and Pt 5's "Pain Screening/Assessment Scale (PS)," dated 11/14/24 were reviewed. RN 8 stated the PO indicated, acetaminophen (a pain reliever and fever reducer medication) 160 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount)/5 milliliter (mL-unit of measure) suspension (liquid) 368mg, ordered dose: 15mg/kilogram (kg-a unit of measurement for weight) x 24 kg oral every four hours as needed for mild pain and temperature greater than 100.4 F with a start date of 11/13/24 and end date of 11/26/24. RN 8 stated the MAR indicated acetaminophen was administered on 11/14/24 at 3:51 p.m. RN 8 stated the PS indicated at 3:53 p.m., Pt 5's pain was 8/10 and Pt 5's pain was not reassessed until 8:21 p.m., a time lapse of four hours and 28 minutes.

During a concurrent interview and record review on 11/25/24 at 3:02 p.m. with RN 8, Pt 4's "H&P," dated 11/14/24 was reviewed. RN 8 stated the H&P indicated Pt 4's chief complaint (primary symptom or concern) was pain and fever.

During a concurrent interview and record review on 11/25/24 at 3:30 p.m. with RN 8, Pt 4's "PO," Pt 4's "MAR," and Pt 4's "PS," dated 11/14/24 were reviewed. RN 8 stated the PO indicated, morphine (a strong pain reliever medication) 4 mg intravenous (IV-given directly into the blood stream) once was ordered at 10:15 a.m. RN 8 stated the MAR indicated, at 10:31 a.m. Pt 4 was administered morphine. RN 8 stated the PS indicated Pt 4's pain was 10/10 (1-least pain and 10-worst possible pain). RN 8 stated a patient's pain should be assessed within an hour of pain medication administration. RN 8 stated Pt 4's pain was not reassessed until 12:45 p.m., which was two hours and 14 minutes after the pain medication was administered.

During an interview on 11/26/24 at 1:40 p.m. with the Director of Acute Care (DAC), the DAC stated her expectations of nurses was to follow the physician's orders. The DAC stated nurses should assess their patient's pain and reassessment of their patient's pain depending on the route the medication was given. The DAC stated when a patient was administered IV pain mediation their pain should be reassessed within 15 minutes and by mouth medications should be assessed within 30 minutes. The DAC stated the importance of assessing and reassessing pain was to determine if the patient's pain was under control. The DAC stated pain control was an important part of healing. The DAC stated she expected nurses to always follow hospital P&P. The DAC stated the importance of nurses following hospital P&P was to ensure evidence-based practices were implemented.

During a review of the hospital's policy and procedure (P&P) titled, "Pain, Management," dated November 2023, the P&P indicated, "Outlines assessment and treatment of pain ...committed to making pain assessment a priority and to developing a pain management plan in collaboration with the patient/family that balances pain relief, safety, side effects ...1. The physician, nurse, and other healthcare professionals ...are educated about pain treatment and collaborate to manage pain in the child ...Proper treatment of a patient's pain will include a careful diagnosis of the etiology of pain, selection of appropriate and cost-effective treatments, and ongoing evaluation of the results of treatment. 3. Pain intensity and pain relief will be assessed and reassessed at regular intervals and will contribute to the choice of appropriate therapeutic intervention. 4. Patients are assessed for pain using developmentally appropriate, reliable methods. 5. Patient assessments, reassessments, interventions, and responses to interventions will be documented ...The [registered nurse (RN)] is accountable to initiate and ensure completion of the teaching plan. An interdisciplinary approach is to be utilized in completion of the plan with input and actual teaching as appropriate from other healthcare team members ...Pain ...An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage ...Expected Outcome(s) ...Appropriate screening and assessment of pain, provision of safe and effective treatment of pain for all patients, and participation of the patient and family in the pain management plan to the greatest extent possible ...Pain Screening and Assessment ...Initial screening and assessment for pain will occur as follows ...Inpatients ...All inpatients will be screened for pain during the initial assessment process ...Pain assessment shall be performed for all patients who screen positive for having pain. This assessment will include the following ...Intensity of pain, reported using the appropriate pain intensity rating scale ...Location(s) of pain for verbal patients, as age-appropriate ...The patient's self-report shall be the primary source of pain assessment information ...Reassessment of pain may include location(s), intensity and effectiveness of pharmacological or nonpharmacological interventions ...Reassessment of pain shall occur at the following points ...With routine vital signs per department standards, regardless of pain intensity level ...Patients who are sleeping do not need to be awakened for a pain rating ...pain should be reassessed upon awakening ...At a suitable interval after each pharmacological or nonpharmacological intervention ...Within 30 minutes after parenteral drug therapy, and within one hour after an oral or rectal medication has been given ...Reassessment after opioid administration should include a pain assessment and assessment for the presence or absence of side effects-including, but not limited respiratory depression ..."

2. During a concurrent interview and record review on 11/25/24 at 10:30 a.m. with RN 8, Pt 5's "PO" and Pt 5's "Blood Transfusion Record (BTR)," dated 11/14/24 were reviewed. RN 8 stated the PO indicated; Pt 5 had an order to transfuse (to transfer into a blood vessel of a person) packed red blood cells (PRBC-a type of blood replacement product used for blood transfusions) on 11/14/24. RN 8 stated the BTR indicated, at 7:45 a.m. the blood transfusion started and Pt 5's temperature was 99 F. RN 8 stated the BTR indicated, at 11 a.m. the blood transfusion stopped and at 11:15 a.m. Pt 5 had a temperature of 101.1 F. RN 8 stated the BTR indicated, the next temperature was assessed at 4:40 p.m., which was a time lapse of five hours and 25 minutes. RN 8 stated Pt 5's temperature should have been rechecked within an hour of the fever, whether a fever reducing medication was administered or not to ensure the fever went down.

During a concurrent interview and record review on 11/25/24 at 10:35 a.m. with RN 8, Pt 5's "Provider Notification (PN)," dated 11/14/24 was reviewed. RN 8 stated the PN indicated, there was no documentation a physician was notified about Pt 5's fever at the end of the blood transfusion. RN 8 stated if her patient had a fever at the end of a blood transfusion, she should have paged or notified the physician about the fever. RN 8 stated the importance of notifying the physician when a patient had a fever after a blood transfusion was to ensure the physician had knowledge about the patient's change in condition and the physician could decide what to do.

During an interview on 11/26/24 at 1:50 p.m. with the DAC, the DAC stated her expectations of nurses when their patient had a fever at the end of a blood transfusion was the fever should have been reported as a potential reaction to the blood. The DAC stated the nurse should have reported to the blood bank and the physician. The DAC stated the importance of reporting a potential reaction was, the reaction could have caused anaphylaxis (a severe life-threatening allergic reaction that could affect the entire body) or the patient could have an infection and in an immunocompromised patient, the patient should of had blood cultures and antibiotics started by contacting the physician.

During a review of the hospital's P&P titled, "Blood Product Management," dated November 2024, the P&P indicated, "Outlines the management of patients receiving selected blood products such as packed red blood cells (PRBC) ...Beginning the Transfusion and Monitoring the Patient ...Obtain and record a full set of baseline vital signs (must be taken within previous 1 hour of initiation of the administration of blood products) then at 15 minutes after the beginning of the transfusion, again at 1 hour, upon completion of the transfusion, and again at approximately 1 hour after the end of the transfusion ...Begin infusion ...over the first 15 minutes, and then advance to the ordered rate after the 15 minute vitals if no adverse reactions are seen ...Closely monitor the patient for the first 15 minutes of the transfusion ...Remain at the bedside for the first 5 minutes of the transfusion ...For the next 10 minutes, continue to watch the patient closely and do not leave the patient unobserved for more than 2-3 minutes ...Intervene immediately should the patient display signs of a severe ...reaction and follow instructions in "Suspected Transfusion Reaction" ...Assess for adverse reactions throughout the transfusion and for an appropriate time thereafter for ...Fever-temperature increase [greater than or equal to] 1 [degree Celsius (C-a scale for measuring temperature, in which water freezes at 0 degrees and boils at 100 degrees)] above baseline vitals ...Itching ...Chills ...Rash ...Respiratory distress ...Explain possible adverse reaction to patient/family, and whom to notify if these are noted ...Instruct the patient/family to report any irritation of the IV site or suspected delayed transfusion reaction ..."

During a review of the hospital's P&P titled, "Transfusion Reactions," dated November 2024, the P&P indicated, "Purpose Statement ...To assist medical and nursing staff in recognizing and managing transfusion reactions and to minimize serious complications that may occur during or after a transfusion ...Transfusing staff shall follow this procedure for the recognition of and response to immediate transfusion reactions and for recording of relevant information in the patient's medical record ...Fever ...An increase of [greater than or equal to] 1 [C] in temperature over the pre-transfusion temperature during or within 4 hours of the completion of the transfusion ...If there are symptoms or findings suggestive of a transfusion reaction, an investigation must be undertaken. Based on the findings of the testing, each complication will be categorized by the pathologist reviewing the case ...Any significant change in a patient's vital signs or status during and up to 6 hours following a transfusion should include an acute transfusion reaction in the differential diagnosis. Early recognition is the key to minimizing serious complications. Signs and symptoms of a transfusion reaction include: Hives, rash, itching ...Warmth at infusion site ...fever ...Headache ...Transfusion Reaction Workup ...For any acute reaction other than mild allergic (rash, hives, itching), or it an investigation is requested by the physician (or pathologist reviewing the case), the transfusing nurse or medical staff should select "Transfusion Reaction-Workup" ...For any acute reaction other than mild allergic (hives, rash, itching), the transfusing nurse or medical staff should take the following action: 1. STOP the transfusion immediately and disconnect the entire transfusion set from the needle or catheter. 2. Keep the IV line open with a slow drip of normal saline, using a new transfusion set. 3. Check the blood bag label and tag against the patient's ID band to confirm that the patient received the correct unit. 4. Notify the attending physician so that treatment, if necessary, can begin immediately. 5. Take vital signs every 15 minutes (including [oxygen] saturation) until the patient is stable. 6. Notify the Blood Bank ([extension] 36066) and describe the signs and symptoms of the reaction. 7. Order a "Transfusion Reaction Workup" in Epic and fill out the information. 8. Send the following items to the Blood Bank [immediately (STAT)]: a. Blood component bag with attached transfusion set and IV fluids. b. Post-transfusion EDTA blood sample: labeled for blood bank. Minimum: 2.0 mL c. Post-transfusion urine specimen if hemolytic reaction is suspected. Minimum: 5.0 mL ..."

3. During a review of Pt 2's "H&P", dated 11/17/24, the H&P indicated, a 17-year-old male was admitted to the hospital from 11/4/24 to 11/15/24 for post-surgical care after right hip surgery.

During a concurrent interview and record review on 11/22/24 at 9:39 a. m. with the Clinical Coordinator (CC) and Nurse Manager (NM) 3, Pt 2's "Wound Care Nurse Note (WCNN)" dated 11/5/2024, 11/8/2024, "Daily Care Flowsheet History (DCFH) dated 11/4/2024 to 11/9/2024" and the facility's P&P titled, "Pressure Injury Risk Assessment and Prevention" were reviewed. The WCNN dated 11/5/24 indicated, " ... Reason for Consult: [Pt 2] is being seen today for a consultative service at the request of [Medical Director (MD)] ... regarding pressure injury prevention ... Assessment ... [Pt 2] is high risk for pressure injury development due to immobility, inactivity and limited response to discomfort ... Plan ...This patient is at risk for pressure injury development to areas ... under all medical devices, and heels ... Recommendations ... Patient Repositioning: Turn [every two hours]. .... Elevate heels off bed ...". The WCNN dated 11/8/24 indicated, " ... Reason for Consult: Pt 2 is being seen at the request of the [Doctor of Osteopathic Medicine (DO)] ... regarding pressure injury treatment, hospital acquired stage 2 pressure injury to right heel; medical device related, abductor pillow and future pressure injury prevention ... [Pt 2] has developed a stage 2 pressure injury to his medial heel... right leg with brace on and is slightly externally rotated [limb away from the body's center]. Both legs in an abductor pillow [soft, firm foam pillow that is used to keep patients' legs aligned and prevent hip movement after surgery]. Right heel is resting on abductor pillow with [dressing] over wound. There is an annular area of non-blanching erythema (skin condition where the redness does not fade when pressed), [2.5 centimeters (cm-unit of measurement by] 3 cm, with a serous filled bulla [fluid filled blister] at center, to the right medial heel .... Initially noted last night, MD was notified, and attempts were made to offload heel as much as possible ... he had/has an abductor pillow in place which as some point his heel rested on, applying unintended pressure to the area ...". The DCFH indicated on 11/5/24 from 7:31 a.m. to 6:23 p.m., on 11/6/24 from 6 a.m. to 6:11 p.m., on 11/7/24 from 8 a.m. to 7:10 p.m., and on 11/8/24 from 8:17 a.m. to 5:30 p.m. there was no documentation to indicate Pt 2's heels had been elevated off the bed. The CC validated Pt 2 did not have a pressure injury when he was admitted on 11/4/24. The CC validated a recommendation was given on 11/5/24 to float Pt 2's heels off the bed and it was not done on 11/5/24, 11/6/24, 11/7/24 and 11/8/24. NM 3 stated Pt 2's heels should have been elevated and not rested on the pillow. NM 3 stated the licensed nurses did not follow the policy and a stage 2 pressure injury developed. NM 3 stated the pressure injury could have been preventable with better attention to the heels. NM 3 stated Pt 2's repositioning should have been more often than the 2 hours.


During an interview on 11/25/24 at 2:25 p. m. with the Wound and Ostomy Specialist (WOS), the Wound and Ostomy Intern (WOI) and the Director Specialty Nursing (DSN). The WOS stated when a patient had a pressure injury a standardized procure (SP) was to be followed which entailed a pressure injury bundle of a physician's orders and a signature is not required, and the SP is covered under the P&P Appendix C "pressure ulcer prevention". The WOS stated nurses were aware of this procedure. The WOS stated the nurses were not following the process, and the nurses should have been offloading the heels and documenting. The WOS stated the importance of offloading the heels were to prevent injury. The WOS stated a pressure injury developed because the process was not followed and was preventable.

During a concurrent interview and record review on 11/26/24 at 11:30 a. m. with Registered Nurse (RN) 6 and NM 5, Pt 5's DCFH dated 11/7/2024 was reviewed. RN 6 stated she was assigned to Pt 2 on 11/7/24 from 7 a.m. to 7:30 p.m. RN 6 stated Pt 2's " ...heels were off the bed ... and his feet were elevated the entire shift ...I forgot to document the heels were elevated off the bed ...". RN 6 stated the importance of elevating heels were to ensure the patient did not get a pressure injury. NM 5 stated the policy was not followed.

During a review of the facility's policy and procedure (P&P) titled, " Pressure Injury Risk Assessment and Prevention ", Policy/Procedure Number PC-4150, dated effective 8/2022, the P&P indicated, "PURPOSE: Guides skin assessment, wound assessment, standardizes pressure injury staging and outlines treatment practices for the care of patients who are experiencing a break in skin integrity. POLICY: All inpatients will be assessed by the registered nurse for risk of skin breakdown, as clinically indicated, at minimum every 12 hours patients who are either partially or completely immobile, neurologically impaired, critically, ... Are at risk for pressure injury development. Effective implementation of pressure injury prevention guidelines requires early identification of heart- risk patients based on risk assessment score and clinical evaluation. QUALIFIED/ APPLICABLE PERSONNEL: RNs are responsible for all aspects of this policy.... PROCEDURE 1. Risk Assessment: A. All patients over 3 weeks old and less than 18 years old shall have a risk assessment evaluation for pressure injury development by a registered nurse upon admission using Braden Q assessment scale (see appendix A) .... D. Reassessment of risk, using Braden Q scale or the Braden scale shall be done every shift or whenever the patient's condition changes or deteriorates. E. All patients shall have a systemic head to toe skin inspection on admission and at least every 12 hours, paying particular attention to Bony prominences and under medical devices. 1. Rotate (as applicable) or release pressure under medical devices including... Heel and elbow protectors... every 4 hours or more often unless physician orders otherwise .... 2. Inspect visible skin surrounding non removable medical devices such as ECLS cannulas, central line cannulas, intravenous lines..., nasal cannula tubing secured with tape/ target them etc., ...a. If redness or skin breakdown is found, the device should be padded, securement readjusted or replaced with a better fitting device as ordered. Attending provider must be notified. b. Leave dressings in place unless removal or dressing changes are ordered. F. Common sites for pressure injury formation includes: ...3. Adolescents and adults hold on sacrum, heel, elbow, ... Under medical devices.2. Prevention ...B. ...3. Bed- bound patients: a. Turn at least every two hours with frequent repositioning, unless specifically contraindicated by physician orders .... d. Suspend or float heels by placing pillow or other positioning device on the patient's calves with knees slightly bent. "do not turn" instructions should require a provider order and be reevaluated every 24 hours .... 5. Medical devices: ...b. Cushion and protect the skin under medical devices with dressing such as foam dressing, and silicone dressing, transparent film, sheets hydrogel etc. c. Ensure patient is not lying on top of any medical device .... e. Rotate or release/ reapply medical devices every four hours unless contraindicated. f. Assess skin in contact with medical device every four hours unless contraindicated. Key points: medical devices known to cause pressure injuries include respiratory devices (masks, cannulas, ETTs, securement devices), immobilizers, orthotics, nasal and enteral feeding tubes, and peripheral and central venous access devices and related securement devices...C. Positioning devices 1. Use heel and elbow protectors, multiple pillows or other padding devices as indicated, to prevent direct contact between Bony prominences (i.e. knees, ankles), and relieve pressure on heels by use of pillows or other positioning devices under the calves to suspend heels off the underlying surface. Assess any sign of foot drop. ...EDUCATION: instruct patient/ family in risk factors, nutrition, skin care and positioning procedures. DOCUMENTATION: Document the following in the medical record: 1. Skin assessment, including baseline score using the Braden Q scale for assessing the risk of pressure injury development. 2. Condition of patient skin, use of special equipment, interventions, and the patient's response. 3.patient/ family teaching.

During the review of a professional reference titled, "Quick Safety 25: Preventing pressure injuries", Updated March 2022 from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/. The reference stated, ...Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries. Other interventions that influence an individual's healing process may include identifying nutritional needs, repositioning and early mobilization, skin care, use of support surfaces, cleansing and debridement, pain assessment and management, psychological and spiritual support, and family support .... Positioning and Mobilization: Immobility can be a big factor in causing pressure injuries. Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis, and coma. Turn and reposition at-risk patients, if not contraindicated. Plan a scheduled frequency of turning and repositioning the patient .... Monitor the prevalence and incidence of pressure injuries. Educate and train all members of the interdisciplinary team. Make sure they are aware of the plan of care and that all care is documented in the patient's record ...."