HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to document repositioning of a patient (Patient #12) as per the facility's policy and wound care orders for seven (7) out of eleven (11) days as a patient in the facility.

Findings:

A review of the medical record for Patient #12 contained the following evidence.

A review of the consult for Wound Ostomy Continence Nurse Eval and Treat for "Reason for Consult? multiple wounds" was signed and dated by the physician on 10/12/2022 at 9:51 a.m.

A review of the Registered Nurse Wound Care note for Patient #12 on 10/12/2022 at 1:43 p.m. contained the documentation "... Braden Scale Score: 6. Assessment: 10/12/22 12:50 p.m. Wound 10/11/22 Pressure Injury Ankle Right; Lateral ... Wound 10/11/22 Pressure Injury Shoulder Right; Posterior ... Wound 10/12/22 Pressure Injury Buttocks Right; Distal ... Wound 10/12/22 Pressure Injury Hip Right; Lateral ... Patient assessed for wounds. Patient noted to have wounds to the right lateral ankle, right ischium, right hip, and right posterior shoulder. All wounds are consistent with prolonged laying on the right side. All wounds are consistent with pressure injuries. The wound to the right posterior shoulder has a shallow opening and is consistent with a stage [two] 2 pressure injury. The other three wound [sic] all present as deep tissue pressure injuries. All wounds are covered with silicone foam dressings. Pillows positioned to patient's right side to turn patient. Plan: Dressing changes to be completed by primary nurse per wound care orders. Moisture management. Nutritional support. Braden Score < 15. Primary RN to order and utilize wedges and heel medix boots from central supply if not already present in room. Aggressive repositioning- reposition patient at least every [two] 2 hours utilizing wedges and pillows to offload pressure from bony prominences. Float Heels- Off load pressure from heels via pillows or heel medix boots [heel protectors designed to help reduce pressure on vulnerable heels - www.vitalitymedical.com] any time patient is in bed...."

A review of the Wound Care Order for Patient #12 that was signed and dated by the physician on 10/12/2022 at 2:38 p.m. contained the documentation "...Comments: Cleanse wounds and surrounding skin with bath wipes. Cover wounds and body prominences with silicone foam dressings. Change every other day and as needed for soiling.... Wound Location: right ankle, right shoulder, right hip, right ischium (the curved bone forming the base of each half of the pelvis - Oxford Dictionary)."

A review of the medical record documentation for Patient #12 contained documentation of the date and time Patient #12 was "turned" or "repositioned" within the "Mobility: Repositioned" flowsheet. The facility's policy titled "Pressure Ulcers Assessment, Prevention, and Management Policy" states in part: ... 1. The Braden Scale for predicting pressure score risk will be completed on every patient daily while in the hospital and will be documented in the medical record. Interventions will be as follows for any patient identified to be at risk: a. Turn and/or reposition at least Q [every two] 2 hours following the turn schedule...."

A review of the medical record documentation for Patient #12 contained documentation of the date and time Patient #12 was "repositioned" within the "Mobility: Repositioned" flowsheet for the patient's eleven (11) day admission from 10/11/2022 through 10/21/2022. There was thirty-two (32) instances when repositioning was documented at greater than every two (2) hours, and most instances of repositioning was documented at four (4) to five (5) hours apart. Specifically, there was documentation of: about twelve (12) hours between repositioning on 10/13/2022 from 7:44 a.m. to 8:01 p.m.; about fifteen (15) hours between repositioning on 10/15/2022 at 4:05 p.m. to 10/16/2022 at 7:35 a.m.; and about eleven (11) hours between repositioning documentation on 10/19/2022 at 8:56 p.m. to 10/20/22 at 7:58 a.m. The was also documentation from 10/17/2020 from 8:52 p.m. to 10/18/2022 at 3:47 p.m. of about nineteen (19) hours documenting that the patient was in "semi-fowlers [a body position at 30 degrees head-of-bed elevation - www.ncbi.nlm.nih.gov]" and/or "supine [lying face upward - Oxford Dictionary]" position during that time frame, with no other position, for example: turned to the left or right side, documented.

During an interview on 5/23/2023 at 3:24 p.m., SM24 stated that a "four (4) eyes skin assessment" is completed on all patients upon admission or when transferred from another unit. As per SM9, staff should write the date and time on the dressing of when the wound dressing was changed or applied. SM9 stated that staff are to reposition patients every two (2) hours unless indicated otherwise ... there is no special way that the staff designate when and which position a patient has been turned ... staff notify each other about the patient's last position in report or communication with other staff. SM9 stated that the facility recently implemented a task on the "worklist" in the electronic medical record system (EMR) that provides a reminder notification to staff reposition the patient and document the repositioning in the medical record. SM9 was unsure which staff have access to document repositioning. SM24 confirmed that the new reminder in the "worklist" was implemented in the "past couple months."

During an interview on 5/24/2023 at 10:44 a.m., SM18 stated that as of March 2023 the facility has implemented an "Impaired Skin Protocol" that automatically populates in all inpatient's orders. SM18 stated that they implemented this nursing protocol because prior to March of 2023 an impaired skin protocol "was not always getting ordered." Any nurse or provider or person that discovers a wound can order the impaired skin protocol. SM19 stated that repositioning patients every two (2) hours is recommended ... the Braden Scale (Tool that can be used to identify patients at-risk for pressure ulcers - Agency for Healthcare Research and Quality www.ahrq.gov.) rating of 15 or less requires for a patient to be repositioned every two (2) hours and is also customized for each patient based on the patient assessment.

During an interview on 5/24/2023 at 2:03 p.m., SM26 (Nursing assistant) recalled that one day after they bathed Patient #12, SM26 only applied the sequential compression devices (SCDs) and pillows to prop the patients feet, and not the heel boots so that the patient's legs could "air out." SM26 stated that typically staff does document position changes, but sometimes when they have twenty-four (24) patients "it may not always get documented." SM26 stated that SM26 was not aware of the "Impaired Skin Protocol" or "wound care order" reminders that appear on the "worklist task" in the EMR.

SM1 provided the surveyor with the "Wound Care Changes: Education Communication" with a date of February 8th, 2023 and the "Wound Care Changes: Overview ... Key Changes ... Details ... Go Live is planned for March 7, 2023" document that SM1 stated was provided as education to the staff regarding the new "Impaired Skin Protocol" implemented in March 2023.

A review of the facility's policy titled "Pressure Ulcers Assessment, Prevention, and Management Policy" states in part:
... 1. The Braden Scale for predicting pressure score risk will be completed on every patient daily while in the hospital and will be documented in the medical record. Interventions will be as follows for any patient identified to be at risk:
a. Turn and/or reposition at least Q [every two] 2 hours following the turn schedule....
Management:
1. Initiate appropriate protocol based on assessment of pressure injury (see protocol order forms) and consult Enterostomal Therapy (ET) Nurse for recommendations and write orders accordingly after notifying the physician.
2. Discuss pressure injury in the interdisciplinary plan of care meeting.
3. Avoid positioning patients on a pressure ulcer.
4. Maintain the head of the bed (HOB) at the lowest degree of elevation consistent with their medical requirements. If medically indicated to have HOB elevated > 30 degrees, then also gatch [to adjust mechanisms on a bed to archive angulation of the mattress, especially elevation of the knee area - thefreedictionary.com] the knees to prevent sliding down in the bed.
5. Off load heels while patient is in the bed.
6. Medicate for pain prior to dressing changes if pressure injury is causing pain.
7. Provide the patient's care-giver with information on preventing pressure injuries.
8. Upon discharge, document the status of the wound and the current treatment plan on the wound care discharge section of the EMR.