HospitalInspections.org

Based on document review and interview, the facility failed to ensure evaluation of nursing care for 4 of 10 (patients 1, 3, 4 and 6's) medical records (MR) reviewed.

Findings include:

1. Review of facility policy, Documentation Standards, last approved 9/30/2018, indicated Patient position if one of the following conditions is met (patient is immobile, on bed rest, has a specific position ordered or a specific order for change of positions): every 2 hours

2. Review of patient 1's MR indicated Orders, Position Patient Q2H (every 2 hours) 02/04/19 12:58:00 EST (Eastern Standard Time) Shift weight off of pressure points if patient unable to turn in bed or sitting in chair

3. Review of patient 1's MR indicated 2/6/2019, at 04:00 am, patient on right, at 6:00 am, patient on right, (lacked position change) 18:00 pm, patient on right, 20:00 pm, patient on right (lacked position change). On 2/9/2019, at 6:00 am, patient on left, at 8:00 am, patient on left (lacked position change). On 2/10/2019, at 6:00 am patient on right, at 8:00 am, patient on right (lacked position change). On 2/11/2018, at 12:00 pm, patient on left, at 14:00 pm, patient on the left (lacked position change).

4. Review of patient 3's MR indicated the following. 02/02/2019, patient complete assist at 6:00 am, patient on left, at 8:00 am, patient on left, (lacked position change). 02/10/2019, patient complete assist at 2/10/2019, at 4:00 am, patient on right, at 6:00 am, patient on right (lacked indication of position change).

5. Review of patient 4's MR indicated the following. 02/05/2019, patient complete assist at 4:00 am, patient on right, at 6:00 am, patient on right (lacked indication of position change). 02/03/2019, patient complete assist at 4:00 am, patient on right, next indication of patient position at 8:00 am, patient on right (lacked indication of position change). 02/03/2019, patient complete assist at 16:00 pm, patient on left, next indication of patient position 20:00 pm, patient on left (lacked indication of position change).

6. Review of patient 6's MR indicated the following. 02/04/2019, patient complete assist at 6:00 am, (unable to determine position) next indication of position was 9:53 am, patient on left (lacked indication of position change). 02/05/2019, patient complete assist at 6:00 am, patient on right, at 8:00 am, patient on right (lacked indication of position change).

7. Interview on 3/12/2019, at approximately 11:30 am, with N3 (Quality Improvement Consultant) confirmed the above.

Based on document review and interview, the facility failed to ensure follow up care needs for 2 of 10 (1 and 3's) patients medical records review (MR).

Findings include:

1. Review of facility policy, Discharge Planning, last approved 10/31/2018, indicated Integrated Care Management is accountable for oversight of the interdisciplinary team collaborative process to ensure continuity of care for each patient/family from admission through transition.

2 .Review of patient 1's MR indicated the following. Nurse View 2/9/2019 and 2/11/2019, included (wounds) Sacrococcygeal, stage 4, L (Left) medial foot: L (Left) dorsal/plantar knee, Left Lower Posterior Other: Extremity, Right Groin, Peri-anal, Left Elbow, Scalp/Occiput., Right Hip, Right, Lower, Medial Leg, Right, Plantar Foot. IP-Discharge Instructions/Medications Clinician Summary, signed by S6 (Medical Doctor) on 2/11/2019 at 12:55 pm, lacked instructions for wound care.

3. Review of patient 3's MR indicated the following. IP-Discharge Instructions/Medications Clinician Summary, signed by N9 (Medical Doctor) on 2/11/2019 at 13:59 pm, indicated take these medications at home. Balsam Peru/castor oil/trypsin topical ...1 App (apply) two times a day to skin (lacked documentation of where to apply). Miconazole topical ...1 App (apply) two times a day to skin (lacked documentation of where to apply).

4. Interview on 3/12/2019, at approximately 11:30 am, with N3 (Quality Improvement Consultant) confirmed the above.