HospitalInspections.org

Based on record review and staff interview, it was determined in 3 of 8 (Pt #4, Pt #5, and Pt #6) patients with wounds, the Hospital failed to ensure the patient was turned in accordance with its policy. This has the potential to affect to affect all in-patients at the Hospital with a current average daily census of 160.

Findings include:

1. The Hospital policy titled "Skin Integrity Protocol" [revised 01/2018] was reviewed 01/21/2021 at approximately 9:00 AM. The policy states "Patients receiving Braden score of 18 or below are considered at risk and are placed on appropriate skin interventions... iii. Implement turning repositioning every 2 hours".

2. The medical record for Pt #4 was reviewed on 01/20/2021. Pt #4 was admitted on 01/17/2021 with diagnoses of Cellulitis Sacral /Buttock. On 01/20/2021 the Braden Scale Score (scale used to assess a patient's risk for developing a pressure ulcer) for Pt #4 was 12. On 01/20/2021 Pt #4 was turned/repositioned at 6:20 AM and not again until 10:30 AM (4 hours 10 minutes). The record lacked documentation the patient was turned every 2 hours per Hospital policy.

3. The medical record for Pt #6 was reviewed on 01/20/2021. Pt #6 was admitted on 01/04/2021 with diagnosis of open wound right foot second toe. On 01/06/21 the Braden Scale Score for Pt #6 was 12. On 01/06/2021 Pt #6 was turned/repositioned at 1:16 AM and not again until 6:00 AM (4 hours 44 minutes). The record lacked documentation the patient was turned every 2 hours per Hospital policy.

4. An interview with the Director of the Intensive Care Unit and 3 Tele Unit (E #5) conducted on 01/20/2021 at approximately 3:00 PM. E #5 agreed with the above findings.


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5. The medical record of pt. #5 was reviewed on 1/19 to 1/21/2021 throughout survey. The pt.was admitted on 12/25/2020 with diagnoses of Urinary Tract Infection and Alcohol Intoxication. The pt. had an open wound upon admission. The Braden Scale Score ranged from 11- 14. The end of shift plan of care included patient to be turned every 2 hours. The flow sheet with skin high risk interventions dated 12/27/20 to 1/6/2021 included reposition/ turn every 2 hours. The repositioning flow sheet dated 1/3/2021 lacked documentation the patient was turned from 11:00 AM to 1749 (6 hours and 49 minutes) every 2 hours. Also 12/30/2020 the repositioning flow sheet lacked documentation the patient was turned from 0800 to 1400 (4 hours). The record lacked documentation the patient was turned every 2 hours.

6. An interview with E# 5 at approximately 2:00 PM on1/21/2021, E#5 verbally confirmed the above findings for pt #5.