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Based on the interview and record review, the hospital failed to enusre that the licensed nurses who provided serviced in the hospital adhered to the policies and procedures of the hospital.

Findings included:

Patient #1 was admitted on 05/22/2022 and presented to an emergency department for a fall while at a baseball game. Evaluation in ER showed a right femoral neck fracture. The patient's Body mass index is 15.99 kg/m². (Classification: Underweight) IBW: 86.4 kg. The patient has physician orders for a Pressure injury prevention score less than or Equal to 18 signed on 05/24/22 at 1520.

Upon interview and record review:

Patient #1 Braden score is less than or equal to 18. The initiation of pressure injury prevention interventions is not according to the hospital policy. There is no Braden scale completed on 05/30/2022 at 09:03 AM. Patient #1 medical record documentation by the nursing staff revealed that the patient is not turned every 2 hours, and keeping the head of the bed elevated is not as per the pressure injury prevention score. Patient #1 is not placed on a specialty surface per the policy.

Braden scores are as follows
Braden Score-16 05/22/22 at 2246
Braden Score-17 05/23/22 at 08:29 AM
Braden Score 17 05/24/22 at 1538
Braden Score 17- 05/24/22 at 1952
Braden Score 18- 05/25/22 at 2318
Braden Score 18- 05/26/22 at 0946
Braden Score- 17 05/27/22 at 0052
Braden Score 18- 05/27/22 at 0915
Braden Score 18- 05/27/22 at 2359
Braden Score 17 -05/29/22 at 1340
Braden Score 05/30/2022 at 0903 AM - No Braden score documentation.
Braden Score 17 -06/01/22 at 2138

Skin intervention
05/23/2022 at 2035 - No turning documentation.
05/24/22 at 1021 - No turning documentation.
05/24/22 at 1952- No turning documentation.
05/25/22 at 1538- No tuning documentation
05/27/22 at 0915- No turning documentation
05/29/22 at 1340- No turning documentation

Positioning
HOB up 30-45 05/26/22 at 0000
HOB up 30-45 05/26/22 at 0100
HOB up 30-45 05/26/2022 0200
HOB up 30-45 05/26/22 at 0400
HOB up 30-45 05/26/22 at 0500
HOB up 30-45 05/26/22 at 0600
HOB up 30-45 05/26/22 at 0700
HOB up 30-45 05/27/22 at 0052
HOB up 30-45 05/27/22 at 0915
HOB up 30-45 05/27/22 at 2352
HOB up 45 degrees 05/29/22 at 0809

Patient #1 is placed on Specialty bed Hill- ROM bed Adbata 2 SAE kit on 06/02/2022 at 1310.

Outcome:
The patient developed a suspected Deep tissue injury on 06/01/2023.

During and inteview on 01/24/2023 at 1300. Personnel #1 and Personnel #2 were informed of the above findings. Personnel # 1 and Personnel #2 were confirmed of the above findings.

According to hospital policy: Skin breakdown Prevention, Pressure injury, Skin tear, Incontinence skin management and Photography Policy Number:PCS318 Approved by: Policy and Procedure Committee 1. Purpose: ...To provide guidance and to communicate the recommended clinical practice in the prevention of skin breakdown...To reduce the incidence of hospital acquired pressure injury...iii Policy Guidance: A role of clinician 1. Nurses a. Perform skin assessment and implement nurseing intervention to prevent skin breakdown. 1) The braden scale for predicting Pressure score risk for adults ...b. Initiate pressure injury prevention interventions for patients with Braden score 18 or below 1) Turn and reposition every 2 hours...2) Keep the head of bed elevated no greated than 30 degree...B. Nursing inteventions and interventions guidelines...2. Prevention of skin breakdown/Routine skin care...d.Request/provide appropriate offloading devices...2) Specialty bed for preventions and treatment of skin breakdown