HospitalInspections.org

Based on document review and interview, nursing failed to ensure complete documentation of repositioning taking place in 1 of 10 medical records reviewed (patient 3).

Findings Include:

1. Review of policy titled: Plan for the Provision of Care, last revised 11/2021, indicated patient services are planned, coordinated, provided, delegated and supervised by professional health care providers based upon findings from assessments. The right interventions and care will be provided according to the established policies, procedures and protocols that have been developed to ensure patient safety. The organizational structure provides for appropriate administration of nursing services on all shifts.

2. Review of patient 3's medical record indicated a doctors order placed on 1/03/24 for repositioning patient every 2 hours. The medical record also indicated a lack of repositioning documentation every 2 hours in the patient's electronic flowsheet: A. 1/12/24 - from 12 pm to 7 pm
B. 1/18/24 - from 11:18 pm to 8:00 am on 1/19/24
C. 1/26/24 - from 2:00 pm to 9:00 pm
D. 1/29/24 - from 11:00 am to 4:00 pm.

3. In interview on 3/04/24 at approximately 5:12 pm, A2 (Accreditation & Regulatory Consultant) confirmed that staff did not document repositioning of patient 3 as ordered and per policy.