HospitalInspections.org

Based on review of medical records, policy and procedure, and interviews with staff, it was determined the facility failed to ensure patients were provided a safe environment to prevent the development of pressure injuries, and failed to follow policy and procedure for patients who refused to be turned and repositioned.

Refer to Tag A 144 for findings.

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the facility failed to ensure a safe environment was provided to prevent the development of pressure injuries. The facility failed to ensure staff followed:

1. The patient's plan of care for at risk, immobile patients.

2. Physician's orders for turning and repositioning patients side to side every 2 hours.

3. The policy for Clinical Response for Patients who Refuse or Fail to Cooperate with Prescribed Medical Treatments.

This affected 2 of 2 medical records reviewed with patients with pressure injuries, and did affect Patient Identifier (PI) # 3 and PI # 1, and had the potential to affect all patients at risk for developing pressure injuries.

Policy: Pressure Injury Prevention
Policy Number: None listed
Revised Date: 2/16/19

...Policy

1. The RN (Registered Nurse) will complete the Braden Risk Assessment Tool on Inpatient Admission and then every shift. If the patient scores 18 or less on the Braden Risk Assessment he/she is to be considered at high risk for pressure injury and "Pressure Ulcer, Actual or Potential" problem should be added to the patient's Plan of Care.

...3. The RN will complete a skin assessment on admission and daily.

4. If the patient is identified to be at risk for pressure injury, turn clocks should be utilized in the patient's room as a reminder to reposition patient every 2 hours as indicated on the clock.

5. The RN will notify the physician of all identified wounds.

...7. Upon identification of a pressure injury, the ET (Enterostomal)/ WOC (Wound, Ostomy, and Continence) Nurse will appropriately stage the wound. After staging of the wound, the RN may initiate treatment as ordered.

...Prevention is the key to avoiding extensive therapy. Preventive measures include off-loading pressure, maintaining adequate nourishment, and ensuring mobility to relieve pressure and promote circulation.

When a pressure injury develops despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration and the use of special equipment to reduce pressure intensity. Treatment may also involve pressure redistribution devices, such as... chair cushions.

...Turn and reposition the patient regularly and frequently... When turning or repositioning the patient, inspect the skin for signs of pressure injury or damage and avoid positioning the patient on areas that have nonblanchable erythema.

...Make sure the patient's heels don't rest on the bed...

Work with the patient and multidisciplinary team to implement a regular repositioning routine because patients at risk for pressure injuries require teaching and encouragement in performing regular repositioning movements to redistribute the buildup of pressure around areas at risk. Post a repositioning schedule at the patient's bedside... Emphasize the importance of regular position changes to the patient...

Direct a patient who is confined to a chair or wheelchair to shift weight every 15 minutes to promote blood flow to compressed tissues.

Show a patient with paraplegia how to shift weight in a wheelchair by doing push-ups. If the patient needs your help, sit next to the patient and help shift the weight to one buttock for 60 seconds; then repeat procedure on the other side. Provide pressure redistribution cushions, as appropriate...

Documentation

Update the care plan, as required. On the clinical record, document a complete skin assessment and interventions used to prevent pressure injuries as well as the patient's response to those interventions.

Policy: Clinical Response for Patients Who Refuse or Fail to Cooperate with Prescribed Medical Treatments
Policy Number: I.A. 110
Date Revised: June 2019 (Formatting Only), November 2017

I. Purpose:

To define process for appropriate caregiver actions when the patient or family refuses prescribed medical treatment or if the patient fails to cooperate with prescribed medical treatments.

II. Policies:

A. DCH (Druid City Hospital) recognizes that competent patients have the right to refuse medical treatment.

B. If the patient refuses or fails to cooperate with treatment, he/she will receive an explanation of possible risk and consequences of this action.

C. The patient's nurse will be notified of any refusal of or failure to cooperate with prescribed medical treatment.

D. Refusal of or failure to cooperate with prescribed medical treatment will be reported to the patient's physician.

E. Refusal of or failure to cooperate with prescribed medical treatment will be documented in the patient's record.

...IV. Procedure:

A. If the patient refuses a prescribed medical treatment or fails to cooperate with a prescribed medial treatment, the caregiver responsible for administering this treatment will reiterate the purpose of the treatment and explain possible risks and consequences of refusal.

B. If the patient continues to refuse/ fail to cooperate... the caregiver (if the caregiver is not the nurse) will notify the nurse.

C. The patient's nurse will speak directly with the patient to confirm that an explanation was provided and that the patient continues to refuse/ fail to cooperate with treatment.

D. Refusal of treatment... will be reviewed with the charge nurse or administrative supervisor to determine the most appropriate method of physician notification. Clinical judgement based on the possible clinical and safety impact of the refusal or failure to cooperate will guide physician notification priority.

...b. Standard priority- communicate with physician as soon as possible during normal business hours... (refusal to... comply with activity orders...).

E. Refusal/failure to cooperate, explanation of possible risk and consequences, name of person involved in explanation, and physician notification will be documented in the patient's record.

1. PI # 3 was admitted to the facility on 3/18/2020 with diagnoses including Traumatic Spinal Cord Dysfunction, and Quadriplegia, Incomplete C (Cervical) 1-4.

Review of the Rehab Nursing Admission Assessment dated 3/18/2020 at 6:39 PM revealed the following documentation:

Neuromuscular:

...Paralysis: Y (Yes) Location: Upper and Lower Body
Weakness: Y Location: All Extremities Unable to Move

Skin Integument:

...Intact: Y
...Edema: N (No)
Rash: N
Bruise/ Hematoma: N
Abrasions: N
Lacerations: N
...Surgical Incisions: Y
Pressure Ulcer Present on Admission: N
Other Skin Ulcers/ Lesions (Not due to Pressure): N

Admission Braden Score: 8
Braden Score of < (less than) or = (equal to) 18, Initiate DX (Diagnosis): Pressure Ulcer, Actual or Potential.

Review of the Plan of Care dated 3/18/2020 included Pressure Ulcer, Actual or Potential, and interventions included Assess Skin Care and Pressure Ulcer Prevention. Activities listed: Turn 2qh, (every 2 hours), Use foam wedge for turning/ positioning, float heels with pillows or waffle boots... place Turn Clock at HOB (Head of Bed)...

Review of the Bedside Nursing Notes dated 3/20/2020 at 11:00 PM until 3/21/2020 at 7:00 AM revealed the patient was positioned on his/her back for 8 hours.

Review of the Bedside Nursing Notes dated 3/21/2020 at 6:00 PM until 3/22/2020 at 7:00 AM revealed the patient was positioned on his/her back for 13 hours.

Review of the Bedside Nursing Notes dated 3/22/2020 at 3:00 PM until 3/23/2020 at 9:00 AM revealed the patient was positioned on his/her back for 18 hours.

Review of the Bedside Nursing Notes dated 3/23/20 at 9:00 PM until 3/24/2020 at 9:00 AM revealed the patient was positioned on his/her back for 12 hours.

Review of the Bedside Nursing Notes dated 3/25/2020 from 5:00 AM to 9:00 AM revealed the patient was positioned on his/her back for 4 hours.

Review of Bedside Nursing Notes dated 3/25/2020 from 9:00 PM to 3/26/2020 at 2:00 AM revealed the patient was positioned on his/her back for 5 hours.

Review of the Bedside Nursing Notes dated 3/26/2020 at 3:00 AM until 10:30 AM revealed the patient was positioned on his/her back for 7.5 hours.

Review of the Bedside Nursing Notes dated 3/28/2020 from 1:01 AM to 4:22 AM, then 5:01 AM to 8:00 AM revealed the patient was positioned on his/her back for 7 hours, with one 38 minute interval where the documented position was on the right side.

Review of the Bedside Nursing Notes dated 3/28/2020 from 11:00 AM to 8:00 PM, revealed the patient was up in wheelchair for 9 hours. There was no documentation the patient's weight was shifted every 15 minutes, per policy.

Review of the Bedside Nursing Notes dated 3/29/2020 from 1:00 AM to 4:15 AM, 3 hours and 15 minutes, and from 5:00 AM to 9:00 AM, 4 hours, revealed the patient was positioned on his/her back.

Review of the Bedside Nursing Notes dated 3/29/2020 at 7:00 PM until 3/30/2020 at 8:00 AM revealed the patient was positioned on his/her back for 13 hours.

Review of the Bedside Nursing Notes dated 3/30/2020 at 5:00 PM until 3/31/2020 at 8:00 AM revealed the patient was positioned on his/her back for 15 hours.

Review of the physician orders dated 3/31/2020 at 10:26 AM revealed an order to Consult ET/WOC Therapy to Evaluate/ Initiate Care for Skin/Wound Care for "Pressure/Sheer/Blisters on Sacrum and Unstageable on Heel Bilaterally."

Review of the Bedside Nursing Notes dated 3/31/2020 from 9:00 PM to 4/1/2020 at 2:00 AM, revealed the patient was positioned on his/her back for 5 hours.

Review of the Patient Notes dated 4/1/2020 at 4:08 AM revealed the following documentation, "...Patient refused to be turn (turned) at this time. PT (patient) is now turned on his/her left side off of his/her bottom." This is the first documentation patient has refused to be turned. There was no documentation the nurse educated the patient on the possible risks and consequences of refusal, per policy.

Review of the Bedside Nursing Notes dated 4/1/2020 from 6:00 AM to 12:00 PM revealed the patient was positioned on his/her back for 6 hours.

Review of the ET Initial Assessment dated 4/1/2020 at 8:20 AM revealed the wound nurse verified the presence of new pressure ulcers, and documented the following 9 wounds, previously undocumented by the nursing staff:

Wound # 1: Sacrum, Stage 2, 3 cm (centimeter) x (by) 1 cm x 0.1 cm.
# 2: Left Heel, DTI (Deep Tissue Injury), 6.5 cm x 8 cm x 0 cm.
# 3: Right Heel, DTI, 5.5 cm x 6 cm x 0 cm.
# 4: Left Top of Foot, DTI, 2.5 cm x 3.5 cm x 0 cm.
# 5: Left 1st Toe, DTI, 0.5 cm x 1 cm x 0 cm.
# 6: Left 2nd Toe, DTI, 0.5 cm x 1 cm x 0 cm.
# 7: Right 5th Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 8: Right 1st Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 9: Right 2nd Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.

Further review of the ET Initial Assessment revealed the following comments, "...Patient found to have several new pressure areas. Sacrum, Stage 2, wound bed is red and has a (an) area of serum filled blister. Will order a silicone foam dressing for this area. Left and right heel DTI, wound bed is red and burgundy. There is a DTI to top of left foot, device related from waffle boot scrap (strap), wound bed is burgundy. DTI to toes from compression hoses, wound beds are burgundy.... Patient is at very high risk for pressure due to immobility.... will follow up in one week."

Review of the physician orders dated 4/1/2020 at 9:52 AM revealed the following orders, "Activity, Turn/Reposition... Turn patient from left to right every two hours. Place turn clock at head of bed... Heel protectors, sleeping... Sacral foam positioners...

Review of the Bedside Nursing Notes dated 4/2/2020 from 12:19 AM to 3:53 AM revealed the patient was positioned on his/her back for 3 hours and 34 minutes.

Review of the Bedside Nursing Notes dated 4/2/2020 at 10:00 PM until 4/3/2020 at 8:30 AM revealed the patient was positioned on his/her back for 10.5 hours.

Review of the Patient Notes dated 4/3/20 at 4:04 AM revealed the following documentation by the RN, "Pt has refused to be turned this shift." There was no documentation the nurse reiterated the purpose of turning or explained the risks and consequences of refusal, according to policy. There was no documentation of physician notification.

Review of the Bedside Nursing Notes dated 4/4/2020 from 5:00 AM to 10:20 AM revealed the patient was positioned on his/her back for 5 hours and 20 minutes.

Review of the Bedside Nursing Notes dated 4/4/2020 from 11:00 AM to 6:00 PM revealed the patient was "Up in wheelchair" for 7 hours. There was no documentation the patient was aided in weight shifting while in the wheelchair, and no documentation of what type of cushion was used.

Review of the Patient Notes dated 4/4/20 at 2:26 PM revealed the nurse documented, "Patient refused to turn this AM." There was no documentation the nurse explained the risks and consequences, or notified the physician, per policy.

Review of the Bedside Nursing Notes dated 4/4/2020 at 7:00 PM until 4/5/2020 at 8:00 AM revealed the patient was positioned on his/her back for 13 hours.

Review of the Bedside Nursing Notes dated 4/5/2020 from 11:00 AM to 8:00 PM revealed the patient was "Up in wheelchair" for 9 hours. There was no documentation the patient was assisted in weight shifting, per policy.

Review of the Bedside Nursing Notes dated 4/5/2020 from 9:00 PM to 4/6/2020 at 6:00 AM revealed the patient was positioned on his/her back for 9 hours.

Review of the Patient Notes dated 4/6/2020 at 12:26 AM revealed the following documentation by the RN, "Nurse went into pt's room to turn him/her. Pt refused." There was no documentation the nurse informed the patient of risks and consequences, or notified the physician, per policy.

Review of the Bedside Nursing Notes dated 4/6/20 at 7:00 PM until 4/7/2020 at 7:00 AM revealed the patient was positioned on his/her back for 12 hours.

Review of the Bedside Nursing Notes dated 4/7/2020 at 5:30 PM until 4/8/2020 at 9:00 AM revealed the patient was positioned on his/her back for 15.5 hours. A bath was documented during this time.

Review of the Patient Notes dated 4/8/2020 at 2:57 AM revealed the following documentation by the nurse, "...he/she refuses to be turned q2hr, wants to be turned only once after being put to bed, around 4 AM... I was doing my duties as a nurse to inform him/her of the recent changes to his/her health. He/She stated, 'You don't have to worry about what happening to me I'm fine.' Noted pt attitude had changed and he/she was agitated some, told him/her I would not be bothering him/her again, but will continue my duties as a nurse..." There was no documentation the physician was notified of the patient's agitation and refusal to turn.

On 4/8/2020 at 10:40 AM a Follow-up Assessment was conducted by the ET nurse. The following wounds were documented:

Wound # 1: Sacrum, UTS (Unable to Stage) 11 cm x 3.5 cm. There was no depth documented. This was increase of 8 cm x 2.5 cm in 7 days.
# 2: Left Heel, DTI, 5.0 cm x 8 cm x 0 cm.
# 3: Right Heel, DTI, 5.5 cm x 4 cm. There was no depth documented.
# 4: Left Top of Foot, DTI, 2.5 cm x 3.5 cm x 0 cm.
# 5: Left 1st Toe, DTI, 0.5 cm x 1 cm x 0 cm.
# 6: Left 2nd Toe, DTI, 0.5 cm 1 cm x 0 cm.
# 7: Right 5th Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 8: Right 1st Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 9: Right 2nd Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
New Wound # 10: Left Ischium, Stage 2, 1.5 cm x 1.0 cm x 0.2 cm.
Comments: "Patient noted with significant decline to sacral wound. Brown tissue noted to wound bed, small amount of pink tissue noted. Patient prefers to sit at a 90 degree angle in the bed and sit up for extended periods of time when in chair. Has low air loss bed. Bed not on this AM upon ET Nurse entering room. ET Nurse plugged bed up and made sure it was functioning properly. Reported findings to nurse and Team Leader..." There was no documentation the physician was notified of the significant decline in the sacral wound.

Review of the Bedside Nursing Notes dated 4/8/2020 at 4:00 PM revealed the patient was positioned on his left side until 4/9/2020 at 8:00 AM, for 16 hours.

Review of the Bedside Nursing Notes dated 4/9/2020 at 5:00 PM to 4/10/2020 3:00 AM revealed the patient was positioned on his/her back for 10 hours.

Further review of the 8:16 PM Assessment revealed the nurse documented, "...Refusing turns Q2H, but will turn occasionally. Educated (education) provided..." There was no documentation the physician was notified of the patient's refusal to turn, per policy.

Review of the Bedside Nursing Notes dated 4/10/2020 at 6:00 PM until 4/11/2020 at 9:00 AM revealed the patient was positioned on his/her right side for 15 hours.

Review of the Patient Notes dated 4/11/2020 at 10:54 AM revealed the following documentation by the nurse, "Maintain proper wound care goal not met. We did provide care of the wounds, but the patient refuses to turn at times. After more education patient finally let us turn him/her this morning." There was no documentation the physician was notified of the patient's refusal of care, per policy.

Review of the Patient Notes dated 4/11/2020 at 11:41 PM revealed the following documentation by the nurse, "...Patient educated about importance of turning again. Patient stated that he does now have a growing concern for his wound, as they are becoming odorous and draining. Informed patient that he/she would be turned from left to right Q2H in order to prevent laying and applying pressure directly to his bottom. Patient stated understanding and has been compliant so far."

Review of the Bedside Nursing Notes dated 4/12/2020 from 5:10 AM to 10:00 PM revealed documentation the patient was positioned on his back for 17 hours.

Review of the Bedside Nursing Notes dated 4/14/2020 from 3:00 PM to 8:00 PM revealed the patient was positioned on his back for 5 hours, and not side to side as ordered.

Review of the Operative Report dated 4/15/2020 revealed a preop diagnosis of Stage IV Extensive Sacral Coccygeal Wound with Quadriplegia, Incontinent of Feces. Name of Procedure: Sharp excisional debridement of skin, subcutaneous tissue, muscle and fascia and the bone of the sacrum and coccyx and transverse colostomy.

Following surgery, the patient was discharged from the Rehabilitation Pavilion and admitted to acute care for monitoring.

An interview was conducted via phone on 5/27/2020 at 8:00 AM with Employee Identifier (EI) # 1, Director, Rehab Services, who confirmed the above findings. EI # 1 further confirmed the patient was not repositioned according to policy and physician orders and the patient's continued refusal to be turned and repositioned was not reported to physician per policy.



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2. PI # 1 was admitted to the facility on 03/11/2020 with diagnoses including Spinal Cord Dysfunction and Paraplegia Complete Related to Cord Compression Syndrome.

Review of the Rehab Nursing Admission Assessment documented on 03/11/2020 at 10:51 PM revealed a Braden score of 14 which prompted to initiate the nursing diagnosis: "Pressure Ulcer, Actual or Potential."

Review of the Plan of Care dated 3/12/2020 included Pressure Ulcer, Actual or Potential, and interventions included Assess Skin Care and Pressure Ulcer Prevention. Additional interventions listed: Activity, Turn/Reposition; Heel Protectors, Sacral Foam Positioners.

MR review revealed a physician order written 03/12/2020 at 10:11 AM for Activity, Turn/Reposition that stated, "Wedge/Body Aligner, Q (every) 2H (hour) Turns. Place Left to Right Turn Clock at HOB (head of bed)."

Further MR review revealed an Enterostomal Therapy Initial Assessment documented 03/12/2020 at 10:21 AM noting reason for consult/evaluation as Pressure Ulcer POA (present on admission). ET nurse documented a wound to the sacrum as wound # 1, classification UTS (unable to stage) POA, 6 cm in length, 6 cm in width, and 0.2 cm depth. Under comments he/she wrote, "Patient is at high risk for pressure due to current illness and decreased mobility."

Review of the Bedside Nursing Notes dated 03/12/2020 at 4:30 PM until 11:00 PM revealed the patient was positioned on his/her back for 6.5 hours.

Review of the Bedside Nursing Notes dated 03/14/2020 at 4:00 AM until 8:10 AM revealed the patient was positioned on his/her right side for 4 hours.

Review of the Bedside Nursing Notes dated 03/15/2020 from 8:35 AM to 4:50 PM had no documentation of patient position or turning for over 8 hours.

Review of the Bedside Nursing Notes dated 03/16/2020 from 3:25 AM until 7:00 AM revealed the patient was positioned on his/her left side 3.5 hours.

Review of the Bedside Nursing Notes dated 03/17/2020 from 4:05 AM to 8:00 AM revealed the patient was positioned on his/her right side 4 hours.

Review of the Bedside Nursing Notes dated 03/20/2020 from 4:00 PM to 7:00 PM revealed the patient was in a wheelchair for 3 hours. There was no documentation of directing or assisting him/her to shift weight every 15 minutes per policy.

Review of the Bedside Nursing Notes dated 03/21/2020 from 2:00 PM to 11:00 PM revealed the patient was positioned on his/her left side for 9 hours.

Review of the Bedside Nursing Notes dated 03/22/2020 from 3:00 AM to 10:30 AM revealed the patient was positioned on his/her right side for 7.5 hours.

Review of the Bedside Nursing Notes dated 03/24/2020 from 12:00 AM to 6:15 AM revealed the patient was positioned on his/her right side for 6 hours.

Review of the Bedside Nursing Notes dated 03/24/2020 from 3:05 PM to 8:00 PM revealed the patient was positioned on his/her back for 5 hours.

Review of the Bedside Nursing Notes dated 03/25/2020 from 12:00 AM to 8:00 AM revealed the patient was positioned on his/her left side for 8 hours.

Review of the Bedside Nursing Notes dated 03/25/2020 from 4:00 PM to 11:00 PM revealed the patient was positioned on his/her back for 7 hours.

Review of the Bedside Nursing Notes dated 03/26/2020 from 3:00 AM to 7:10 AM revealed the patient was positioned on his/her right side for 4 hours.

Review of the Bedside Nursing Notes dated 03/27/2020 from 3:00 PM to 11:00 PM revealed the patient was positioned on his/her right side for 8 hours.

Review of the Bedside Nursing Notes dated 03/28/2020 from 3:00 PM to 11:00 PM revealed the patient was positioned on his/her back for 8 hours.

Review of the Bedside Nursing Notes dated 03/29/2020 from 6:00 AM to 2:44 PM had no documentation of patient position or turning for over 7.5 hours.

Review of the Bedside Nursing Notes dated 03/30/2020 from 12:00 AM to 5:00 AM had no documentation of patient position or turning for 5 hours.

Review of the Bedside Nursing Notes dated 03/31/2020 from 5:00 PM to 9:00 PM revealed the patient was positioned on his/her left side for 4 hours.

Review of the Bedside Nursing Notes dated 04/02/2020 from 12:15 AM to 8:00 AM revealed the patient was positioned on his/her right side for 8 hours.

An interview was conducted via phone on 5/28/2020 at 9:00 AM with EI # 1, who confirmed the above findings. EI # 1 further confirmed the patient was not repositioned according to policy and physician orders.

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the facility failed to ensure staff turned and repositioned immobile patients per physicians orders and policy, and failed to document wound assessments and wound care.

Refer to Tag A 392 for findings.

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the facility failed to ensure staff:

1. Followed the nursing plan of care for patients with a Braden Risk Assessment score of 18 or less, per policy.

2. Repositioned immobile patients every 2 hours to prevent pressure injuries.

3. Followed physician orders to turn patient side to side every 2 hours.

4. Documented wound assessments per policy.

5. Provided wound care per physician's orders.

6. Notified physician of patient's continued refusal of care, per policy.

This affected 2 of 2 MR's reviewed of patients with pressure injuries, including Patient Identifiers (PI) # 3 and PI # 1, and had the potential to affect all patients at risk for pressure injuries.

Policy: Pressure Injury Prevention
Policy Number: None listed
Revised Date: 2/16/19

...Policy

1. The RN (Registered Nurse) will complete the Braden Risk Assessment Tool on Inpatient Admission and then every shift. If the patient scores 18 or less on the Braden Risk Assessment he/she is to be considered at high risk for pressure injury and "Pressure Ulcer, Actual or Potential" problem should be added to the patient's Plan of Care.

...3. The RN will complete a skin assessment on admission and daily.

4. If the patient is identified to be at risk for pressure injury, turn clocks should be utilized in the patient's room as a reminder to reposition patient every 2 hours as indicated on the clock.

5. The RN will notify the physician of all identified wounds.

...7. Upon identification of a pressure injury, the ET (Enterostomal)/ WOC (Wound, Ostomy, and Continence) Nurse will appropriately stage the wound. After staging of the wound, the RN may initiate treatment as ordered.

...Prevention is the key to avoiding extensive therapy. Preventive measures include off-loading pressure, maintaining adequate nourishment, and ensuring mobility to relieve pressure and promote circulation.

When a pressure injury develops despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration and the use of special equipment to reduce pressure intensity. Treatment may also involve pressure redistribution devices, such as... chair cushions.

...Turn and reposition the patient regularly and frequently... When turning or repositioning the patient, inspect the skin for signs of pressure injury or damage and avoid positioning the patient on areas that have nonblanchable erythema.

...Make sure the patient's heels don't rest on the bed...

Work with the patient and multidisciplinary team to implement a regular repositioning routine because patients at risk for pressure injuries require teaching and encouragement in performing regular repositioning movements to redistribute the buildup of pressure around areas at risk. Post a repositioning schedule at the patient's bedside... Emphasize the importance of regular position changes to the patient...

Direct a patient who is confined to a chair or wheelchair to shift weight every 15 minutes to promote blood flow to compressed tissues.

Show a patient with paraplegia how to shift weight in a wheelchair by doing push-ups. If the patient needs your help, sit next to the patient and help shift the weight to one buttock for 60 seconds; then repeat procedure on the other side. Provide pressure redistribution cushions, as appropriate...

Documentation

Update the care plan, as required. On the clinical record, document a complete skin assessment and interventions used to prevent pressure injuries as well as the patient's response to those interventions.

Policy: Acute Spinal Cord Injury Care
Policy Number: None listed
Date Revised: 2/15/19

... Policy

...Provide meticulous skin care:

To prevent pressure injuries, reposition the patient at an interval determined by the patient's tissue tolerance, level of activity, skin condition...

Keep the area under the patient clean and dry.

Inspect the skin under equipment and minimize or eliminate pressure caused by equipment.

Consider the use of prophylactic dressing to prevent sacral and heel pressure injuries.

Documentation

...Document baseline skin assessment findings... as well as interventions implemented to prevent skin breakdown.

Policy: Clinical Response for Patients Who Refuse or Fail to Cooperate with Prescribed Medical Treatments
Policy Number: I.A. 110
Date Revised: June 2019 (Formatting Only), November 2017

I. Purpose:

To define process for appropriate caregiver actions when the patient or family refuses prescribed medical treatment or if the patient fails to cooperate with prescribed medical treatments.

II. Policies:

A. DCH (Druid City Hospital) recognizes that competent patients have the right to refuse medical treatment.

B. If the patient refuses or fails to cooperate with treatment, he/she will receive an explanation of possible risk and consequences of this action.

C. The patient's nurse will be notified of any refusal of or failure to cooperate with prescribed medical treatment.

D. Refusal of or failure to cooperate with prescribed medical treatment will be reported to the patient's physician.

E. Refusal of or failure to cooperate with prescribed medical treatment will be documented in the patient's record.

...IV. Procedure:

A. If the patient refuses a prescribed medical treatment or fails to cooperated with a prescribed medial treatment, the caregiver responsible for administering this treatment will reiterate the purpose of the treatment and explain possible risks and consequences of refusal.

B. If the patient continues to refuse/ fail to cooperate... the caregiver (if the caregiver is not the nurse) will notify the nurse.

C. The patient's nurse will speak directly with the patient to confirm that an explanation was provided and that the patient continues to refuse/ fail to cooperate with treatment.

D. Refusal of treatment... will be reviewed with the charge nurse or administrative supervisor to determine the most appropriate method of physician notification. Clinical judgement based on the possible clinical and safety impact of the refusal or failure to cooperate will guide physician notification priority.

...b. Standard priority- communicate with physician as soon as possible during normal business hours... (refusal to... comply with activity orders...).

E. Refusal/failure to cooperate, explanation of possible risk and consequences, name of person involved in explanation, and physician notification will be documented in the patient's record.

Policy: Wound Assessment
Policy Number: None listed
Revised Date: 8/17/18

Policy

A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. Comprehensive wound assessment is necessary during every dressing change. Comparison of assessment results to previous findings helps to monitor, communicate, treat, and document wound healing or complications.

...Implementation

...During removal of a patient's wound dressing, inspect the dressing to assess wound drainage...

Assess the color of the wound...

Measure the wound... the longest area... measure the widest width... measure depth... Assess the surrounding areas...

Documentation

Record the... location, size, and appearance of the wound site... presence or absence of drainage. Include the color, type, amount, and odor of any drainage present.

1. PI # 3 was admitted to the facility on 3/18/2020 with diagnoses including Traumatic Spinal Cord Dysfunction, and Quadriplegia, Incomplete C (Cervical) 1-4.

Review of the Rehab Nursing Admission Assessment dated 3/18/2020 at 6:39 PM revealed the following documentation:

Neuromuscular:

...Paralysis: Y (Yes) Location: Upper and Lower Body
Weakness: Y Location: All Extremities Unable to Move

Skin Integument:

...Intact: Y
...Edema: N (No)
Rash: N
Bruise/ Hematoma: N
Abrasions: N
Lacerations: N
...Surgical Incisions: Y
Pressure Ulcer Present on Admission: N
Other Skin Ulcers/ Lesions (Not due to Pressure): N

Admission Braden Score: 8
Braden Score of < (less than) or = (equal to) 18, Initiate DX (Diagnosis): Pressure Ulcer, Actual or Potential

There was no documentation of an assessment of the surgical wound referenced above.

Review of the Plan of Care dated 3/18/2020 included Pressure Ulcer, Actual or Potential, and interventions included Assess Skin Care and Pressure Ulcer Prevention. Activities listed: Turn 2qh, (every 2 hours), Use foam wedge for turning/ positioning, float heels with pillows or waffle boots... place Turn Clock at HOB (Head of Bed)...

Review of the Bedside Nursing Notes dated 3/20/2020 at 11:00 PM until 3/21/2020 at 7:00 AM revealed the patient was positioned on his/her back for 8 hours.

Review of the Bedside Nursing Notes dated 3/21/2020 at 6:00 PM until 3/22/2020 at 7:00 AM revealed the patient was positioned on his/her back for 13 hours.

Review of the Bedside Nursing Notes dated 3/22/2020 at 3:00 PM until 3/23/2020 at 9:00 AM revealed the patient was positioned on his/her back for 18 hours.

Review of the Bedside Nursing Notes dated 3/23/20 at 9:00 PM until 3/24/2020 at 9:00 AM revealed the patient was positioned on his/her back for 12 hours.

Review of the Bedside Nursing Notes dated 3/25/2020 from 5:00 AM to 9:00 AM revealed the patient was positioned on his/her back for 4 hours.

Review of Bedside Nursing Notes dated 3/25/2020 from 9:00 PM to 3/26/2020 at 2:00 AM revealed the patient was positioned on his/her back for 5 hours.

Review of the Bedside Nursing Notes dated 3/26/2020 at 3:00 AM until 10:30 AM revealed the patient was positioned on his/her back for 7.5 hours.

Review of the Bedside Nursing Notes dated 3/28/2020 from 1:01 AM to 4:22 AM, then 5:01 AM to 8:00 AM revealed the patient was positioned on his/her back for 7 hours, with one 38 minute interval where the documented position was on the right side.

Review of the Bedside Nursing Notes dated 3/28/2020 from 11:00 AM to 8:00 PM, revealed the patient was up in wheelchair for 9 hours. There was no documentation the patient's weight was shifted every 15 minutes, per policy.

Review of the Bedside Nursing Notes dated 3/29/2020 from 1:00 AM to 4:15 AM, 3 hours and 15 minutes, and from 5:00 AM to 9:00 AM, 4 hours, revealed the patient was positioned on his/her back.

Review of the Bedside Nursing Notes dated 3/29/2020 at 7:00 PM until 3/30/2020 at 8:00 AM revealed the patient was positioned on his/her back for 13 hours.

Review of the Bedside Nursing Notes dated 3/30/2020 at 5:00 PM until 3/31/2020 at 8:00 AM revealed the patient was positioned on his/her back for 15 hours.

Review of the physician orders dated 3/31/2020 at 10:26 AM revealed an order to Consult ET/WOC Therapy to Evaluate/ Initiate Care for Skin/Wound Care for "Pressure/Sheer/Blisters on Sacrum and Unstageable on Heel Bilaterally."

Review of the Bedside Nursing Notes dated 3/31/2020 from 9:00 PM to 4/1/2020 at 2:00 AM, revealed the patient was positioned on his/her back for 5 hours.

Review of the Patient Notes dated 4/1/2020 at 4:08 AM revealed the following documentation, "...Patient refused to be turn (turned) at this time. PT (patient) is now turned on his/her left side off of his/her bottom." This is the first documentation patient has refused to be turned. There was no documentation the nurse educated the patient on the possible risks and consequences of refusal, per policy.

Review of the Bedside Nursing Notes dated 4/1/2020 from 6:00 AM to 12:00 PM revealed the patient was positioned on his/her back for 6 hours.

Review of the ET Initial Assessment dated 4/1/2020 at 8:20 AM revealed the wound nurse verified the presence of new pressure injuries, and documented the following 9 wounds, previously undocumented by the nursing staff:

Wound # 1: Sacrum, Stage 2, 3 cm (centimeter) x (by) 1 cm x 0.1 cm.
# 2: Left Heel, DTI (Deep Tissue Injury), 6.5 cm x 8 cm x 0 cm.
# 3: Right Heel, DTI, 5.5 cm x 6 cm x 0 cm.
# 4: Left Top of Foot, DTI, 2.5 cm x 3.5 cm x 0 cm.
# 5: Left 1st Toe, DTI, 0.5 cm x 1 cm x 0 cm.
# 6: Left 2nd Toe, DTI, 0.5 cm x 1 cm x 0 cm.
# 7: Right 5th Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 8: Right 1st Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 9: Right 2nd Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.

Further review of the ET Initial Assessment revealed the following comments, "...Patient found to have several new pressure areas. Sacrum, Stage 2, wound bed is red and has a (an) area of serum filled blister. Will order a silicone foam dressing for this area. Left and right heel DTI, wound bed is red and burgundy. There is a DTI to top of left foot, device related from waffle boot scrap (strap), wound bed is burgundy. DTI to toes from compression hoses, wound beds are burgundy.... Patient is at very high risk for pressure due to immobility.... will follow up in one week."

Review of the physician orders dated 4/1/2020 at 9:52 AM revealed the following orders, "Activity, Turn/Reposition... Turn patient from left to right every two hours. Place turn clock at head of bed... Heel protectors, sleeping... Sacral foam positioners... Dressing Apply/Change... Body Site: Top of left foot, left heel, right heel, left 1st (first) toe, left 2nd (second) toe, right 1st toe, right 2nd toe, right 5th (fifth) toe. Comments: Clean DTI's (Deep Tissue Injuries) with Vashe, Apply Venelex, and leave open to air BID (twice a day)... Clean Stage II pressure ulcer to sacrum with Vashe; cover with silicone foam border dressing Q2D (every 2 days) and PRN (as needed).

Review of the Bedside Nursing Notes dated 4/2/2020 from 12:19 AM to 3:53 AM revealed the patient was positioned on his/her back for 3 hours and 34 minutes.

Review of the Rehab Shift Assessment dated 4/2/2020 at 1:05 AM revealed the nurse documented the following 4 wound locations (no wound numbers were listed): "Neck," "Head," "Right Foot/Heel," and "Left Foot and Sacral Area." The left foot and sacral area were listed as one wound. The RN further documented, "...Also noted stage 2 area to sacral areas with 3 - 4 multiple red spots noted about dim (dime) size irregular. Cleaned well..." There was no documentation the new wounds were reported to the ET nurse or physician, and there was no documentation of what was used to clean the wound.

Review of the Rehab Shift Assessment dated 4/2/2020 at 9:45 AM revealed the nurse failed to document assessment of all 9 wounds. There was no documentation the DTI's were cleaned with Vashe as ordered. The left foot and sacral area are listed as one wound. The documented dressing type was 'Dry Dressing,' and Other: Cleaned and new mepilex applied. The surveyor was unable to determine which wound had the dry dressing and new mepilex applied.

Review of the Rehab Shift Assessment dated 4/2/2020 at 9:00 PM revealed the nurse failed to document all wounds. The wound locations were changed to "Bilateral Heels," and "Buttocks," with no assessment documented of the sacral wound. There was no documentation any of the wounds were cleaned with Vashe as ordered.

Review of the Bedside Nursing Notes dated 4/2/2020 at 10:00 PM until 4/3/2020 at 8:30 AM revealed the patient was positioned on his/her back for 10.5 hours.

Review of the Patient Notes dated 4/3/20 at 4:04 AM revealed the following documentation by the RN, "Pt has refused to be turned this shift." There was no documentation the nurse reiterated the purpose of turning or explained the risks and consequences of refusal, according to policy. There was no documentation of physician notification.

Review of the Rehab Shift Assessments dated 4/3/2020 at 8:29 AM and 8:27 PM revealed the following wound locations, "Bilateral Heels," "Buttocks," "Right Foot/Heel," and "Left Foot and Sacral Area." There was no documentation of the 5 DTI's to the toes. There was no documentation the wounds were cleaned with Vashe as ordered. For the location "Left Foot and Sacral Area," the surveyor was unable to determine the care given to which wound.

Review of the Bedside Nursing Notes dated 4/4/2020 from 5:00 AM to 10:20 AM revealed the patient was positioned on his/her back for 5 hours and 20 minutes.

Review of the Bedside Nursing Notes dated 4/4/2020 from 11:00 AM to 6:00 PM revealed the patient was "Up in wheelchair" for 7 hours. There was no documentation the patient was aided in weight shifting while in the wheelchair, and no documentation of what type of cushion was used.

Review of the Patient Notes dated 4/4/20 at 2:26 PM revealed the nurse documented, "Patient refused to turn this AM." There was no documentation the nurse explained the risks and consequences, or notified the physician, per policy.

Review of the Bedside Nursing Notes dated 4/4/2020 at 7:00 PM until 4/5/2020 at 8:00 AM revealed the patient was positioned on his/her back for 13 hours.

Review of the Rehab Shift Assessment dated 4/4/20 at 7:45 PM revealed the nurse documented two wound locations, "Bilateral Heels," and "Buttocks." There was no documentation of assessment of the sacral pressure ulcer, DTI's to top of left foot, or 5 toes. There was no documentation any of the wounds were cleaned with Vashe per orders.

Review of the Rehab Shift Assessments dated 4/5/2020 at 7:36 AM and 7:55 PM revealed the nurses failed to document assessment of all wounds, or document any of the wounds were cleaned with Vashe per orders.

Review of the Bedside Nursing Notes dated 4/5/2020 from 11:00 AM to 8:00 PM revealed the patient was "Up in wheelchair" for 9 hours. There was no documentation the patient was assisted in weight shifting, per policy.

Review of the Bedside Nursing Notes dated 4/5/2020 from 9:00 PM to 4/6/2020 at 6:00 AM revealed the patient was positioned on his/her back for 9 hours.

Review of the Patient Notes dated 4/6/2020 at 12:26 AM revealed the following documentation by the RN, "Nurse went into pt's room to turn him/her. Pt refused." There was no documentation the nurse informed the patient of risks and consequences, or notified the physician, per policy.

Review of the Bedside Nursing Notes dated 4/6/20 at 7:00 PM until 4/7/2020 at 7:00 AM revealed the patient was positioned on his/her back for 12 hours.

Review of the Patient Notes dated 4/7/2020 at 2:43 PM revealed the RN documented the following, "(Name) with ET told me the recommendation was not to place a mepilex on him/her because it needed to "Dry Out" some. The order has not been changed. I reached out to ET and left a message that the order/recommendation needed to be changed." There was no new order written.

Review of the Bedside Nursing Notes dated 4/7/2020 at 5:30 PM until 4/8/2020 at 9:00 AM revealed the patient was positioned on his/her back for 15.5 hours. A bath was documented during this time.

Review of the Patient Notes dated 4/8/2020 at 2:57 AM revealed the following documentation by the nurse, "...he/she refuses to be turned q2hr, wants to be turned only once after being put to bed, around 4 AM... I was doing my duties as a nurse to inform him/her of the recent changes to his/her health. He/She stated, 'You don't have to worry about what happening to me I'm fine.' Noted pt attitude had changed and he/she was agitated some, told him/her I would not be bothering him/her again, but will continue my duties as a nurse..." There was no documentation the physician was notified of the patient's agitation and refusal to turn.

On 4/8/2020 at 10:40 AM a Follow-up Assessment was conducted by the ET nurse. The following wounds were documented:

Wound # 1: Sacrum, UTS (Unable to Stage) 11 cm x 3.5 cm. There was no depth documented. This was an increase in wound size of 8 cm x 2.5 cm in 7 days.
# 2: Left Heel, DTI, 5.0 cm x 8 cm x 0 cm.
# 3: Right Heel, DTI, 5.5 cm x 4 cm. There was no depth documented.
# 4: Left Top of Foot, DTI, 2.5 cm x 3.5 cm x 0 cm.
# 5: Left 1st Toe, DTI, 0.5 cm x 1 cm x 0 cm.
# 6: Left 2nd Toe, DTI, 0.5 cm 1 cm x 0 cm.
# 7: Right 5th Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 8: Right 1st Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
# 9: Right 2nd Toe, DTI, 0.5 cm x 0.5 cm x 0 cm.
New Wound # 10: Left Ischium, Stage 2, 1.5 cm x 1.0 cm x 0.2 cm.
Comments: "Patient noted with significant decline to sacral wound. Brown tissue noted to wound bed, small amount of pink tissue noted. Patient prefers to sit at a 90 degree angle in the bed and sit up for extended periods of time when in chair. Has low air loss bed. Bed not on this AM upon ET Nurse entering room. ET Nurse plugged bed up and made sure it was functioning properly. Reported findings to nurse and Team Leader..."

A physician's order dated 4/8/2020 at 10:45 AM revealed the following, "Cleanse Stage 2 to left ischium with Vashe, apply small silicone foam dressing Q3D (Every 3 Days). Encourage patient to offload off of sacrum."

Review of the Bedside Nursing Notes dated 4/8/2020 at 4:00 PM revealed the patient was positioned on his left side until 4/9/2020 at 8:00 AM, for 16 hours.

Review of the Rehab Shift Assessment dated 4/8/2020 at 11:00 PM revealed the nurse documented Skin Intact: "Y" (Yes), Newly Identified Pressure Ulcer: "N" (No). The ET Nurse documented a new pressure ulcer at 10:40 AM the same day. For the location, "Left Foot and Sacral Area" the nurse documented Dressing type: Wound left open, and Other: Cleaned and added butt paste. There was no order to leave the wound open. There was no documentation of assessment of the other DTI's of the toes, or cleaning with Vashe as ordered.

Review of the Rehab Shift Assessment dated 4/9/2020 at 7:40 AM revealed the nurse documented Skin Intact: "Y." For the wound location Left Foot, the nurse documented Other: Cleaned and added a mepilex for blistered area that ruptured. There was no documentation the nurse notified the ET nurse or physician of the change in the wound status. There was no documentation of assessment of the DTI's to the toes, or cleaning of the wounds with Vashe as ordered.

Review of the Bedside Nursing Notes dated 4/9/2020 at 5:00 PM to 4/10/2020 3:00 AM revealed the patient was positioned on his/her back for 10 hours.

Review of the Rehab Shift Assessment dated 4/9/2020 at 9:17 PM revealed the following wound documentation:
L (Left) Ischium dressing type: Wound left open, Other: Mepilex
Sacrum dressing type: Wound left open, Other: Mepilex
Left Foot dressing type: Wound left open, Other: ...Mepilex.
The surveyor was unable to determine if the three wounds listed above were left open or had a Mepilex dressing applied.

Review of the Rehab Shift Assessments dated 4/10/2020 at 8:35 AM and 8:16 PM revealed the following same wound documentation:
L (Left) Ischium dressing type: Wound left open, Other: Mepilex changed today.
Sacrum dressing type: Wound left open, Other: Mepilex applied changed today.
Left Foot dressing type: Wound left open, Other: ...Mepilex.
The surveyor was unable to determine if the three wounds listed above were left open or had a Mepilex dressing applied.

Further review of the 8:16 PM Assessment revealed the nurse documented, "...Refusing turns Q2H, but will turn occasionally. Educated (education) provided..." There was no documentation the physician was notified of the patient's refusal to turn, per policy.

Review of the Bedside Nursing Notes dated 4/10/2020 at 6:00 PM until 4/11/2020 at 9:00 AM revealed the patient was positioned on his/her right side for 15 hours.

Review of the Rehab Shift Assessment dated 4/11/2020 at 7:20 AM revealed the following wound documentation:
L Ischium/ Buttocks: Dressing type: Wound left open. Other: Three small open areas, cleaned and applied mepilex.
Sacrum: Dressing type: Wound left open. Other: Area has a yellow brown color and had some drainage. Very odorous. Cleaned the area and applied a mepilex.
Left foot: Dressing type: Wound left open. Other: Cleaned and added mepilex for blistered area that ruptured.
The surveyor was unable to determine if wounds were left open or dressed with mepilex. The CRNP (Certified Registered Nurse Practitioner) was notified of the three small open areas on the actual buttocks. There was no documentation the ET nurse was notified.

Review of the Patient Notes dated 4/11/2020 at 10:54 AM revealed the following documentation by the nurse, "Maintain proper wound care goal not met. We did provide care of the wounds, but the patient refuses to turn at times. After more education patient finally let us turn him/her this morning." There was no documentation the physician was notified of the patient's refusal of care, per policy.

Review of the Patient Notes dated 4/11/2020 at 11:41 PM revealed the following documentation by the nurse, "...Patient educated about importance of turning again. Patient stated that he does now have a growing concern for his wound, as they are becoming odorous and draining. Informed patient that he/she would be turned from left to right Q2H in order to prevent laying and applying pressure directly to his bottom. Patient stated understanding and has been compliant so far."

Review of the Bedside Nursing Notes dated Sunday, 4/12/2020 from 5:10 AM to 10:00 PM revealed documentation the patient was positioned on his back for 17 hours.

Review of the Rehab Shift Assessment date 4/13/2020 at 8:09 AM revealed the sacrum wound was left open and "...butt paste applied after shower with OT (Occupational Therapy). The L ischium/ buttocks was left open and "...butt paste applied after shower." The order for both wounds reads "...clean with Vashe and cover with silicone foam dressing." The RN failed to perform wound care as ordered.

Review of the Rehab Shift Assessment dated 4/13/2020 at 8:20 PM revealed documentation of 2 wounds, not 10 as established by the ET nurse. The two locations documented were as follows:
Location: Bilateral Heels/feet, no documentation of cleansing with Vashe per orders.
Location: Sacrum, other: 85 % of wound bed covered with brown and black adherent tissue. Remaining tissue yellow surrounding edges of black/brown tissue. Pink edges. Applied butt paste and covered with foam dressing. There was no documentation the wounds were cleaned with Vashe per orders. And no documentation of assessment and cleaning of the L ischium, top of left foot and 5 toes.

Review of the Rehab Shift Assessment dated 4/14/2020 at 8:07 AM revealed the nurse continued to document butt pasted applied and not cleaned with Vashe as ordered, for both the sacrum and L ischium. Dressing type for L ischium: Wound left open, and Other: ...covered with mepilex. The surveyor was unable to determine if the wound was left open or covered.

Review of the Bedside Nursing Notes dated 4/14/2020 from 3:00 PM to 8:00 PM revealed the patient was positioned on his back for 5 hours, and not side to side as ordered.

Review of the Rehab Shift Assessment dated 4/14/2020 at 8:00 PM revealed Dr. (surgeon) was there to look at sacral wound and to debride in AM. Nurse documented cleaning sacral wound with surgical soap. There was no documentation all other wounds were cleaned with Vashe as ordered.

Review of the Operative Report dated 4/15/2020 revealed a preop diagnosis of Stage IV Extensive Sacral Coccygeal Wound with Quadriplegia, Incontinent of Feces. Name of Procedure: Sharp excisional debridement of skin, subcutaneous tissue, muscle and fascia and the bone of the sacrum and coccyx and transverse colostomy.

Following surgery, the patient was discharged from the Rehab Pavilion and admitted to acute care for monitoring.

An interview was conducted via phone on 5/27/2020 at 8:00 AM with Employee Identifier (EI) # 1, Director, Rehab Services, who confirmed the above findings. EI # 1 further confirmed the patient was not repositioned according to policy and physician orders, all wounds were not assessed and documented according to policy, wound care was not performed and documented as ordered, and the patient's continued refusal to be turned and repositioned was not reported to physician per policy.



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2. PI # 1 was admitted to the facility on 03/11/2020 with diagnoses including Spinal Cord Dysfunction and Paraplegia Complete Related to Cord Compression Syndrome.

Review of the Rehab Nursing Admission Assessment documented 03/11/2020 at 10:51 PM stated "no" to Pressure Ulcer Present on Admission. Assessment also documented a Braden score of 14 which prompted to initiate the nursing diagnosis: "Pressure Ulcer, Actual or Potential."

Review of the Plan of Care dated 3/12/2020 included Pressure Ulcer, Actual or Potential, and interventions included Assess Skin Care and Pressure Ulcer Prevention. Additional interventions listed: Activity, Turn/Reposition; Heel Protectors, Sacral Foam Positioners.

MR review revealed a physician order written 03/12/2020 at 10:11 AM for Activity, Turn/Reposition that stated, "Wedge/Body Aligner, Q (every) 2H (hour) Turns. Place Left to Right Turn Clock at HOB (head of bed)."

Further MR review revealed an Enterostomal Therapy Initial Assessment documented 03/12/2020 at 10:21 AM noting reason for consult/evaluation as Pressure Ulcer POA (present on admission). ET nurse documented a wound to the sacrum as wound # 1, classification UTS (unable to stage) POA, 6 cm in length, 6 cm in width, and 0.2 cm depth. Under comments he/she wrote, "patient found to have an UTS POA to sacrum. Wound bed is red, yellow and black, periwound is blanchable. Has a foul odor, spoke with Dr. (physician name) regarding a surgical consult for patient. Will order santyl BID dressing changes. Patient is at high risk for pressure due to current illness and decreased mobility."

Review of the Bedside Nursing Notes dated 03/12/2020 at 4:30 PM until 11:00 PM revealed the patient was positioned on his/her back for 6.5 hours.

Review of the Bedside Nursing Notes dated 03/14/2020 at 4:00 AM until 8:10 AM revealed the patient was positioned on his/her right side for 4 hours.

Review of the Bedside Nursing Notes dated 03/15/2020 from 8:35 AM to 4:50 PM had no documentation of patient position or turning for over 8 hours.

Review of the Bedside Nursing Notes dated 03/16/2020 from 3:25 AM until 7:00 AM revealed the patient was positioned on his/her left side 3.5 hours.

Review of the Bedside Nursing Notes dated 03/17/2020 from 4:05 AM to 8:00 AM revealed the patient was positioned on his/her right side 4 hours.

Review of the Bedside Nursing Notes dated 03/20/2020 from 4:00 PM to 7:00 PM revealed the patient was in a wheelchair for 3 hours. There was no documentation of directing or assisting him/her to shift weight every 15 minutes per policy.

Review of the Bedside Nursing Notes dated 03/21/2020 from 2:00 PM to 11:00 PM revealed the patient was positioned on his/her left side for 9 hours.

Review of the Bedside Nursing Notes dated 03/22/2020 from 3:00 AM to 10:30 AM revealed the patient was positioned on his/her right side for 7.5 hours.

Review of the Bedside Nursing Notes dated 03/24/2020 from 12:00 AM to 6:15 AM revealed the patient was positioned on his/her right side for 6 hours.

Review of the Bedside Nursing Notes dated 03/24/2020 from 3:05 PM to 8:00 PM revealed the patient was positioned on his/her back for 5 hours.

Review of the Bedside Nursing Notes dated 03/25/2020 from 12:00 AM to 8:00 AM revealed the patient was positioned on his/her left side for 8 hours.

Review of the Bedside Nursing Notes dated 03/25/2020 from 4:00 PM to 11:00 PM revealed the patient was positioned on his/her back for 7 hours.

Review of the Bedside Nursing Notes dated 03/26/2020 from 3:00 AM to 7:10 AM revealed the patient was positioned on his/her right side for 4 hours.

Review of the Bedside Nursing Notes dated 03/27/2020 from 3:00 PM to 11:00 PM revealed the patient was positioned on his/her right side for 8 hours.

Review of the Bedside Nursing Notes dated 03/28/2020 from 3:00 PM to 11:00 PM revealed the patient was positioned on his/her back for 8 hours.

Review of the Bedside Nursing Notes dated 03/29/2020 from 6:00 AM to 2:44 PM had no documentation of patient position or turning for over 7.5 hours.

Review of the Bedside Nursing Notes dated 03/30/2020 from 12:00 AM to 5:00 AM had no documentation of patient position or turning for 5 hours.

Review of the Bedside Nursing Notes dated 03/31/2020 from 5:00 PM to 9:00 PM revealed the patient was positioned on his/her left side for 4 hours.

Review of the Bedside Nursing Notes dated 04/02/2020 from 12:15 AM to 8:00 AM revealed the patient was positioned on his/her right side for 8 hours.

An interview was conducted via phone on 5/28/2020 at 9:00 AM with EI # 1, who confirmed the above findings. EI # 1 further confirmed the patient was not repositioned according to policy