HospitalInspections.org

I. Based on document review and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure the nursing staff followed the hospital's policies and procedures for skin care on 3 of 3 intensive care unit (ICU) discharged patients reviewed for Deep Tissue Injury (DTI). Please refer to A-0395.

2. Ensure the nursing staff followed the hospital's Nursing Practice Process Standards for repositioning and range of motion to patients to prevent or reduce development of Deep Tissue Injuries (DTI). Please refer to A-0395.

The cumulative effect of these policy and procedure failures and deficient practices resulted in the hospital's inability to ensure the nursing staff safely provided nursing care and failed to implement interventions to ensure intubated ICU patients did not develop pressure ulcers.

Based on document review, observation and staff interviews the hospital failed to implement interventions to ensure patients admitted did not acquire pressure ulcers (Deep Tissue Injuries:DTI) for 3 of 3 sampled discharged ICU patients (Patients #1, #2, and #3). On 9/7/17 the facility reported a census of 12 patients in the ICU, of which 3 patients were intubated and sedated.

Failure to implement interventions to prevent skin breakdown can result in additional health complications including death.

Findings include:

1. A document titled "Nursing Practice Process Standards," provided on 8/30/17 at 10:15 AM by the ICU Nurse Manager, revealed the following: "The nursing process is used to identify and address the patient's environmental, physical...needs...The registered nurse (RN) is accountable and responsible for patient care..."

The section titled Nursing Practice Standards included but not limited to the following:
a. Skin integrity is assessed using the Braden Scale on admission and daily (except ambulatory Obstetric patients),
b. An appropriate plan of nursing care is formulated...to meet hospitalization and post hospital needs.
c. Health Care Patterns...observe integrity of skin including perianal area and pressure points...consult ET referral for skin breakdown...maintain body alignment, reposition every 2-4 hours, provide active/passive range of motion to arms and legs twice daily and as needed for patients on bed rest unless contraindicated.

2. Observation on 9/7/17 at approximately 11:17 AM revealed 12 patients in the Intensive Care Unit. Observation revealed 2 of 3 patients intubated and sedated were placed on low air loss mattresses for pressure redistribution. One (1) patient intubated and sedated had a waffle air overlay on the mattress.

ICU Clinical Practice Expert stated ICU and SCU beds are interchangeable. In April/May, 2017 the facility received 6 new Stryker beds that have the capability to convert into a low air loss mattress but they did not purchase that portion of the new bed related to cost. The remaining beds were foam mattress, and did not provide pressure redistribution.

The ICU Clinical Practice Expert stated most ICU intubated patients are probably at risk for skin breakdown and nursing staff does their best to apply pressure reducing interventions as soon as possible.

ICU Clinical Practice Expert stated if a patient arrives to ICU from the floor and requires intubation/sedation staff do not always apply a pressure reducing mattress related to airway concerns identified as emergent.

ICU Clinical Practice Expert stated the 6 new Stryker beds and the 12 Hill Rom beds have the ability to reposition the by change the elevation of the head of the bed, any cardiac position, trendelenburg, etc however that does not alleviate a pressure area.



3. Record review of Patient #1's medical record dated 6/1/17 at 3:27 AM, showed Patient #1 presented to the Emergency Department (ED) with complaints of severe abdominal pain and constipation.

a. An X-ray report dated 6/1/17 at 4:13 AM revealed inflammatory changes on multiple loops of bowel suggestive of enteritis, colonic diverticulosis and small ascites.

b. The initial History and Physical (H&P) reflected no skin concerns identified. The ED physician admitted Patient #1 for surgical consult.

Following a surgical procedure for bowel resection, Patient #1 declined with diagnoses including but not limited to: sepsis, encephalopathy, acute respiratory distress (ARD) with hypoxia, severe sepsis with septic shock, acute infarct small intestine, diverticulitis with perforated abscess and peritonitis. Patient #1 required admission to the Intensive Care Unit (ICU) for emergent interventions, intubated and heavily sedated while in ICU.

c. Nursing integumentary assessments dated 6/3/17 - 6/5/17 assessed the patient's skin as "WDL" (normal limits) with a Braden Score of 13. Nursing assessments checked "yes" to indicate nursing staff checked the following: inflation or air mattress, reposition schedule and Mepilex and/or pillows placed.
The patient's medical record did not specify the type of air or inflation mattress utilized.

d. A nursing assessment, dated 6/4/17 at 8:00 PM, revealed Patient #1's skin warm and dry with a blister.
The assessment lacked a measurement or description of the blister, and lacked evidence to indicate nursing staff implemented an intervention to prevent additional skin breakdown.

e. An initial skin assessment, dated 6/8/17 at 2:00 PM, revealed RN AA, ICU Clinical Practice Expert registered nurse (RN) assessed a suspected deep tissue injury on the patient's back. RN AA assessed the wound as follows: 5 centimeter (cm) x 0.25 cm that increases to 1.5 cm when opened, nonblanching, purple, with fluid filled tiny blisters on the right side.

The wound assessment failed to include a complete wound assessment to include but not limited to: specific wound location, a complete and thorough assessment of the blisters (i.e. size, number, if fluid filled, intact, etc.), and assessment of the wound's perimeter.

The patient's medical record failed to include additional wound assessment information such as measurement, color, or odor which could indicate deterioration of the pressure ulcer.

Additionally, the clinical record lacked evidence nursing staff implemented additional interventions to prevent skin breakdown.

f. Patient #1's medical record included documentation of family consultation and education by Wound Ostomy Continence Nurse (WOCN) CC regarding ostomy care on 6/3/17, 6/6/17 and 6/13/17.
WOCN CC did not assess Patient #1's pressure ulcer.

(WOCN CC provided WOCN services from 5/3/17 - 7/3/17 during facility employed WOCN BB's leave.)

g. During an interview on 8/22/17 at 4:49 PM Patient #1's family member stated Patient #1 had abdominal surgery, then admitted to ICU for 9 days.
The family member observed a large bandage on Patient #1's lower back and was informed. nursing staff applied the bandage because the patient slept a lot. Patient #1's (pressure sore) back started in the ICU and is still present. The family member observed the patient with pillows to position but did not recall the patient on his/her side.

The medical record revealed Patient #1's date of discharge as 6/17/17, approximately 2 months prior to the interview.


4. Record review of Patient #2's medical record revealed Patient #2 presented to the ED on 7/18/17 at 12:56 PM per air ambulance.

a. The initial H&P revealed admission diagnoses included but not limited to: Methicillin Sensitive Staphylococcus Aurous (MSSA), acute kidney failure with tubular necrosis, severe sepsis with shock, metabolic encephalopathy, pneumonia, diabetes mellitus with ketoacidosis without coma and acute respiratory distress. The H&P identified a right below knee amputation (BKA) and no skin concerns. The H&P included patient pertinent past medical history included Methicillin-resistant staphylococcus aureus (MRSA) and necrotizing fascitis, also known as flesh eating disease.

b. The medical record revealed Patient #2 required intubation, sedation and Continuous Renal Replacement Therapy (CRRT is a dialysis modality used to treat critically ill patients in the ICU who develop acute kidney injury) while in ICU.

Patient #2 remained in the facility intensive care units from 7/18/17 - 8/3/17.

Patient #2 transferred to the medical floor on 8/3/17.

Patient #2 discharged from the acute care hospital to a skilled nursing facility on 8/15/17.

c. Nursing integumentary assessments dated 7/18/17 - 7/21/17 assessed the patient's skin as "WDL" (normal limits) with a Braden Score of 10. A Braden Score of 10-12 indicates the patient is at high risk to develop pressure ulcers. Nursing assessments revealed nursing staff checked "yes" to indicate nursing staff checked the following interventions: repositioned the patient every 2 hours and positioned the patient with pillows.

The patient's medical record did not include information regarding the type mattress utilized.

Nurses Notes and physician progress notes identified no skin concerns identified.

d. A nurse's note, dated 7/21/17 at 4:20 AM, revealed nursing staff identified a deep tissue injury. The nurse's note failed to include an assessment of the deep tissue injury and failed to identify an intervention to prevent new and/or continued deterioration of identified skin breakdown.

e. A WOCN consultation note, dated 7/26/17, revealed WOCN BB assessed Patient #2's deep tissue injury as follows: red/purple, nonblanchable, blistering, deroofing, that continues to evolve with changes in the wound base to dark red/black. WOCN BB noted the deep tissue injury was not present on admission.

f. During an interview on 8/23/17 at 9:10 AM Patient #2 stated (he/she) continues to receive skilled services in a skilled nursing facility. Patient #2 stated there's still a sore on my bottom and assumed the sore resulted from not being turned while hospitalized.

Patient #2 did not understand why nursing staff did not reposition (him/her) or implement a special mattress upon ICU admission. While in ICU, one staff member constantly remained at the patient's bedside. Patient #2's sibling reported nursing staff applied a special mattress after identification of the pressure ulcer.

Patient #2 continues to require wound care by nursing staff in addition to consultation by a wound nurse. The patient's wound is painful and requires a special bed. Patient #2 is not able to lie on (his/her) back without pain.

Patient #2 stated the last sore (hospital acquired pressure ulcer) required a "special machine" attached to the wound (wound vac) and hoped this wound would heal without that device. Patient #2 stated appreciation for life saving measures provided by the nursing staff however frustrated because the painful wound as a result of their failure to provide appropriate turning and a specialized mattress to prevent pressure ulcers.

g. During an interview on 9/6/17 at 3:50 PM Patient #2's spouse stated while in ICU Patient #2's bed was black and flat. Nursing staff noticed a pressure ulcer 3 days after admitted to ICU, then changed to a special mattress. The patient's spouse stated nursing staff repositioned Patient #2 a little bit the first couple days, and repositioned the patient "a lot" after they identified the pressure ulcer.

Patient #2's staff stated prior to the pressure ulcer, 1 nursing staff placed a pillow under Patient #2's arm. After the pressure ulcer, 1 nursing staff rolled Patient #2, and 1 nursing staff placed a pillow under the patient's bottom.

The spouse recalled WOCN BB assessed the pressure ulcer and requested a (plastic) surgeon evaluate the area. The patient's wound is still "black."




4. Record review of Patient #3's medical record, dated 7/25/17 at 3:06 AM, revealed Patient #3 presented to the Emergency Department (ED) with complaints of chest pain. Patient #3 was admitted to the hospital for telemetry (a method used to monitor heart rhythm).

a. The initial H&P, dated 7/25/17, revealed no skin concerns identified.

b. Patient #3 deteriorated and required emergent surgical intervention, and transfer to ICU on 7/27/17 related to post-operative concerns. The patient required intubatation and sedation.

c. Nursing integumentary assessments dated 7/27/17 - 7/31/17 assessed the patient's skin as "WDL" (normal limits) with Braden Scores of 10 - 12. A Braden Score of 10-12 indicates the patient is at high risk to develop pressure ulcers. Nursing assessments revealed nursing staff checked "yes" to indicate nursing staff checked the following interventions: inflation or air mattress checked, and repositioning schedule followed.

The patient's medical record did not include information regarding the type mattress utilized or the frequency of repositioning.

d. A nurse's note, dated 7/31/17 at 10:54 AM, revealed nursing staff identified a "purple/red/pink open area with superficial area surrounding dark skin discoloration" on the patient's coccyx.
The nurse's note failed to include specific assessment documentation such as a measurement, drainage, odor, etc.

The medical record failed to include documentation of an intervention implemented to prevent new and/or continued wound deterioration.

d. A WOCN note, dated 8/1/17 at 2:45 PM, revealed WOCN BB received notification nursing staff identified a pressure ulcer on 7/31/17. WOCN BB assessed Patient #3's sacral-coccygeal pressure area as 0.5 cm x 0.5 cm x 0.1 cm with periwound 7 x 3.5 x 0.1 cm. WOCN BB assessed the wound appeared a deep tissue injury that evolved to Stage 2 pressure ulcer (described as a partial-thickness los of skin with exposed dermis; the wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister). WOCN BB assessed Patient #3's Braden Score 10.

WOCN BB implemented application of a low air loss mattress.

Staff interviews as follows:

a. During an interview on 8/30/17 at 12:25 PM Staff Registered Nurse (RN) A, Intensive Care Unit (ICU) RN, stated she worked with Patient #3. Patient #3 was intubated and "super sick." Initially Patient #3 was on a regular ICU bed. Patient #3 could not independently reposition while intubated and sedated. The patient's buttocks became red and staff applied a waffle overlay on the patient's bed. RN described the waffle overlay as a hand pumped overlay placed on top of the bed.

Patient #3 developed a pressure ulcer on the coccyx approximately one week after admitted to ICU. Staff applied the air overlay after staff identified the pressure ulcer.
RN A stated nursing staff still reposition patients while intubated, and while on CRRT.
RN A stated there was a different intubated patient that desaturated (a drop in oxygen) with movement. The physician directed staff not move the patient (Patient #2). RN A could not recall if the physician wrote an order that directed staff not reposition a patient or if this was nursing communication.

RN A stated any time the patient's Braden score is less than 17 and not moving, the protocol is apply a static overlay i.e. a waffle mattress. If staff identify skin breakdown on the patient's coccyx, or a patient has a lower Braden score, an air overlay is utilized.

RN A stated normally patients start with the waffle mattress. RN A stated we should chart which mattress is used. (A Braden score is an assessment tool to identify the potential for skin breakdown. A Braden score of 15-18 indicates mild risk. A lower the score indicates a higher risk for skin breakdown.)

RN A stated she normally completes a Braden Scale twice on the day shift.

RN A stated ICU nurses have been short staffed. RN A stated we try to turn patients every 2 hours, but sometimes it can be 2.5 - 3 hours. RN A stated ICU patients have been very ill and require 1:1 which can make the shift very hectic.

b. During an interview on 8/30/17 at 1:04 PM ICU RN B stated she provided nursing care to Patient #3. Initially Patient #3 was alert, however developed respiratory distress and required intubation.

RN B stated usually a long term patient has a waffle air overlay on the mattress. An air overlay was applied after staff identified Patient #3's pressure ulcer. RN B identified pressure ulcers to Patient #3's feet.

RN B stated the ICU has been short nursing staff. They utilize traveling nurses (nurses temporarily assigned to the hospital) and have several new/less experienced ICU nursing staff. Some nurses prioritize repositioning a patient; however, nurses with less experience that provide nursing care to patients on a ventilator find it difficult to reposition the patient.

RN B worked on the overnight shift and day shift. The over night staff provide bed baths for patients on a ventilator. If a patient is on a ventilator, staff place a Mepilex dressing (protective dressing) on their coccyx. The Mepilex dressing is pulled back to allow the nursing staff to observe the coccyx, and reapplied if not soiled. RN B stated night staff checks the coccyx however do not chart that.

c. During an interview on 8/30/17 at 1:42 PM ICU RN E stated Patient #3 developed a pressure ulcer to the coccyx while hospitalized. RN E stated the high number of pressure ulcers in the ICU relates to equipment. The waffle mattress is like a blow up mattress used in a swimming pool, and not effective in reducing pressure areas. RN E stated nursing staff needs to roll patients.

RN E expressed concerns regarding the lack of specialized ICU beds to prevent skin breakdown but the expense is always a factor. RN E stated you have to check the waffle mattress every shift to ensure proper inflation, but there's no real test to check for proper inflation, leak or slow air loss.

RN E stated ICU night staff is improving, however still short and lacks experience. Night shift "makes do" with available staff, but there are probably occasions when patients are not turned every 2 hours.

RN E stated night shift give bed baths to patients on a ventilator. Mepilex dressings are standard and applied at admission. Nursing staff pull the edge of the Mepilex back during the bed bath to observe the patient's skin. If the Mepilex dressing is not soiled, staff reapplies the dressing.

RN E stated the patient's skin could sheer when staff pull the Mepilex dressing back if the incorrect size is applied.

d. During an interview on 8/30/17 at 2:37 PM, Registered Respiratory Therapist (RRT) G stated recollection of Patients #1, #2, and #3. RRT G could not recall a patient that could not be repositioned while sedated on the ventilator. Usually if the patient desaturates they recover quickly including patients with acute respiratory distress.

e. During an interview on 8/30/17 at 6:54 PM ICU RN I stated nursing staff roll ICU patients to remove linens. RN I recalled Patient #2 and the pressure ulcer. A nurse informed RN I to not reposition patient #2 because the oxygen saturation dropped.

RN I was unsure how long nursing staff did not reposition the patient or if there was a physician's order that directed staff to not move Patient #2. Patient #2 required CRRT. RN I stated fluid can be an issue with tissue for patients on CRRT and, "we just didn't turn (him/her)." RN I stated nursing staff completed bed baths to the top side of Patient #2's body.

RN I thought nursing staff could reposition the patient's feet.

RN I stated Patient #3 had a long hospital stay. RN I provided nursing care to Patient #3 the day after staff identified the pressure ulcer. RN I turned Patient #3 from side to side.

RN I stated ICU uses Stryker beds. Nursing staff add a waffle mattress if a patient is at risk for skin breakdown. After nursing staff identify skin problems, an air overlay is applied.

e. During an interview on 8/31/17 at 12:43 PM ICU RN M stated a lot of pressure ulcers in ICU are the result of intubation. RN M stated you can't do large position changes with an intubated patient.

f. During an interview on 8/30/17 at 3:29 PM ICU RN H stated nursing staff position ICU patients with pillows under arms. Pressure relieving mattresses such as a waffle mattress or low air mattress for patients identified at risk for skin breakdown or pressure ulcers.
RN H stated nursing staff pump the waffle mattress by hand. Nursing staff place their hand under the waffle mattress to ensure appropriate inflation. If the nurse feels the patient's bottom too much, they hand pump additional air into the mattress. Nurses try to check the appropriate inflation every time patients are turned.

RN H provided nursing care to Patient #3. RN H could not recall the type of mattress used for Patient #3.

g. During an interview on 9/7/17 at 12:50 PM ICU RN V stated if an ICU patient is at risk for skin breakdown, a waffle mattress is placed. Nursing staff inflate the waffle mattress with about 40 or more pumps. ICU RN V stated to check appropriate inflation, staff place a hand under the air mattress. The mattress can not be so light that your hand easily goes under the air mattress, but can't be too full so your hand can't move under the mattress. The nurse should be able to feel the patient's bottom a little bit. The patient should not be sitting on the actual bed mattress.

ICU RN V stated once he had a patient that had a specialized air overlay that arrived from a city approximately an hour away. The air overlay actually did the patient turning for nursing staff. ICU RN V stated that patient was morbidly obese and did not develop a pressure ulcer.


h. During an interview on 8/23/17 at 10:11 AM ICU Clinical Practice Expert stated Patient #2 had diagnoses that included severe sepsis that required intubation, sedation and CRRT. Patient #2 had clear skin a day or 2 before staff identified the DTI, deep tissue injury. A deep tissue injury is a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise.

The ICU Clinical Practice Expert stated the physician ordered staff not move the patient because Patient #2 became unstable with any movement. After nursing staff identified the DTI, they reviewed the do not move order with the physician. The physician did not want the patient repositioned. The ICU Clinical Practice Expert could not recall which physician directed staff not move Patient #2.

The ICU Clinical Practice Expert stated Patient #2 had limited activity from Friday - Sunday (3 days). The ICU Clinical Practice Expert stated the decision to not reposition a patient on the ventilator is very rare and physician based. The ICU Clinical Practice Expert did not work over the weekend, and received notification of the DTI upon return to work on Monday.
The ICU Clinical Practice Expert stated by Monday, Patient #2 improved and nursing staff could reposition the patient.

On 8/23/17 at 11:24 AM the ICU Clinical Practice Expert stated she was unable to locate a physician's order to not move Patient #2.

i. During an interview on 8/24/17 at 10:01 AM ICU RN Nurse Manager stated if a patient in the ICU develops a DTI or Stage 3 pressure ulcer the WOCN is consulted to evaluate and initiate interventions. ICU Nurse Manager stated the nursing standard for a ventilated patient is to turn the patient every 2 hours unless medically unstable, such as CRRT. When a patient is on CRRT, most of the time the patient is on pressors and will kink the flow if moved. Recently several ICU patients were so unstable that any movement would cause complications resulting in a need for change in medications (pressors). In those situations, staff to do not turn the patient. This may or may not require a physician's order however that is in the nursing scope of practice.

Nurses try to implement the appropriate mattress for patients at admission, however at night that may be a difficult task. The ICU Nurse Manager stated she is trying to get new beds for the ICU. At the time Patient #2 was admitted to the ICU, all specialized beds were utilized.

The hospital has some specialized mattress and some low air loss overlays, but not enough for each ICU room. The ICU Manager stated specialized beds are not just standard, there are multiple different levels for beds. She was not certain how many specialized beds were currently available for patients at risk.

The ICU Nurse Manager stated all ICU patients are at high risk because they're not mobile. Staff try to assure a specialized mattress is available for each patient however they have to prioritize.

The ICU Nurse Manager expects nursing staff notify the WOCN when a skin concern is identified, and communicate with the physician. The ICU Nurse Manager stated skin has to be a conscious thought process and with ICU many areas are involved.

j. During an interview on 8/23/17 at 1:16 PM the WOCN nurse stated she was aware of the deep tissue injuries identified for Patients #1, #2, and #3. The WOCN stated she was off from 5/9/17 - 7/3/17. WOCN BB is the only WOCN in the hospital.

WOCN BB stated RN AA notified her regarding Patient #2's deep tissue injury. WOCN BB wanted plastics involved as soon as possible.

WOCN BB stated when espressos all blood goes to the main part of the body and outliers with any pressors (espressos) develop ischemia and unfortunately do not recover. Interventions are needed early to prevent pressure ulcers. WOCN BB stated typically staff implement a special bed, especially if intubated for greater than 24 hours to prevent pressure areas. Patients that are immobile with an amputation would be identified as a risk. WOCN stated unfortunately I was not notified at the time of Patient #2's admission.

WOCN BB stated staff do not complete wound assessments to include measurements, but need to. The WOCN provides education when able.

WOCN BB stated staff applies a Mepilex dressing as prevention if skin is intact. The dressing should be changed every 3-5 days, sooner if soiled.

WOCN BB stated the likely cause of the ICU deep tissue injuries is likely pressors and shearing. A patient can develop a pressure ulcer over a short amount of time. Additionally, patients on espressos may not have been turned enough. Interventions should include pressure reducing mattress. Patients identified at risk need upgraded to a static low air loss mattress (waffle mattress). Nursing judgement can drive the physician's order for the low air loss mattress.

The WOCN stated the hospital has other true low air loss mattresses in house. If the supply is out, the vendor can deliver within 8-10 hours.

WOCN BB stated 2 nurses were told to not move Patient #2. WOCN BB stated nursing staff can perform "microturns" or implement a special low air loss mattress prior to initiating CRRT.

WOCN BB stated Patient #2 had a history of MRSA and necrotizing fasciitis which would be considered co-morbidities staff should identify.

k. During an interview on 8/24/17 at 8:34 AM Physician N, pulmonology, stated there is no contraindication for a specialized mattress to help distribute patient's weight. The nursing staff make those decisions after evaluating the risk of the development of skin concerns and implement accordingly. A patient with CRRT and ARDS is very sick and requires high concentrations of oxygen. We actually recommend don't move or move minimally. Usually one lung is more effective than the other to prevent oxygen desaturation. This is very rare and not long term. Physician N stated nursing staff could apply a pressure reducing mattress prior to initiating CRRT if needed.

l. During an interview on 8/28/17 at 1:33 PM Physician M, pulmonary disease, stated he would not say nursing staff were unable to move an intubated patient on CRRT. Physician M did not see a contraindication to initiate specialized low air loss mattress prior to initiating CRRT.

m. During an interview on 9/5/17 at 3:59 PM Physician L, nephrologist, stated he very rare gives a physician's order do not move a patient. He added maybe one time when he saw Patient #3 he may have directed nurses not to move the patient but for only 2-3 hours. Physician L stated he never directed staff do not move a patient for 2-3 days. Physician M very rarely would write an order to direct staff not move a patient.

Observation on 9/7/17 at 10:13 AM revealed 12 patients in the ICU. 3 of the patients were on ventilators. At the time of the observation 2 patients beds had a low air loss mattress overlay placed and one patient had a waffle mattress overlay. The ICU Nurse Manager stated the waffle cushion is considered a pressure reduction.

During a follow up interview with the ICU Nurse Manager, the ICU Nurse Manager stated if a patient is critical, staff do not always think about implementing a low air loss mattress.

Depending on support services, it doesn't take long to have a lot air loss mattress delivered, however if a patient is unstable the 1st goal is not to get the patient on a low air loss mattress. Ideally at the time nursing report is provided would be effective because they are aware the patient is on a ventilator.

The ICU Nurse Manager stated she requested capital for different beds and we do the best we can with the variables provided for every patient. The ICU Nurse Manager stated if a patient is intubated and sedated the standard is to turn the patient every 2 hours. The hospital skin policy directs turn the patient every 4 hours.

The ICU Nurse Manager confirmed 3 DTI injuries is pretty significant pressure areas, however 2 of the 3 identified were very ill and unstable. Nursing staff did not turn these patients because they had a drop in pressures,so turning is not an option. The ICU Nurse Manager stated the nurse is left to decide do you clot the catheter or save the patient's skin. Nursing staff shifted and positioned Patient #2 with pillows.

The ICU Nurse Manager stated the dialysis catheter can be turned but the flow decreased. Patient #2 was unstable for some time, and nursing staff did end up putting a low air loss mattress on. The ICU Nurse Manager stated our resources have been challenged with the acuity of our patients. Patient #2 often required 2 nurses. When nursing staff are trying to safely provide nursing care for all patients they prioritize the needs.

The ICU Nurse Manager stated she reviewed the medical records for Patients #1, #2 and #3 and admitted there is room for documenting opportunities.

The ICU Nurse Manager stated if a patient is unstable and has soiled linens and on multiple pressors and nursing staff are trying to keep the patient alive, nursing staff will tuck the linens and leave them until the patient is stable to move. Specifically if a patient's oxygen is 67% and has soiled linens, I'm not going to turn the patient to decrease the oxygen saturation to the 40's. The wait to change the linens could be 30 minutes or an hour, depends on the patient.

The ICU Nurse Manager then stated the low air loss overlays are rolled and placed under the patient, just as linens are rolled and placed.