HospitalInspections.org

Based upon document review and interview, the registered nurse failed to follow the policy/procedures for skin and wound care and ensure all patients at risk for skin breakdown were regularly repositioned for 1 of 6 medical records (MR) reviewed (patient #1).

Findings include:

1. The policy/procedure Adult Skin and Wound Care (approved 2-14) indicated the following: "Prevention measures will be instituted for all patients determined to be at risk through the Braden assessment (Braden score equal to or less than 18)... K- Keep Turning. Reposition patient frequently... Wound Care... Stage 1. Relieve pressure. Turn/reposition frequently; keep patient positioned off area... Stage 2. Relieve pressure. Turn/reposition frequently... Stage 3. Rescue skin by relieving all pressure to the injured area. Turn/reposition frequently..."

2. Review of the MR for patient #1 indicated on 9-26-15 at 1231 hours that the patient was evaluated on admission to be at high risk for skin breakdown (Braden score = 11) and indicated an area of non-intact skin was present on the sacrum that was believed to be a deep tissue injury.

3. The MR indicated on 9-26-15 at 1400 hours that patient #1 was positioned on their back in bed and no documentation indicated the patient was repositioned on either side until the MR entry on 9-27-15 at 0200 hours indicated the patient was repositioned onto their left side.

4. On 4-29-16 at 1615 hours, the administrative director of quality, staff A1, confirmed the MR for patient #1 failed to indicate the patient was repositioned off their back from 9-26-15 at 1400 hours until 9-27-15 at 0200 hours when the MR indicated the patient was repositioned on their left side.

5. Review of the MR for patient #1 indicated on 9-26-15 at 0800 hours that the patient was evaluated to be at moderate risk for skin breakdown (Braden score = 13).

6. The MR indicated on 9-27-15 at 1000 hours that patient #1 was positioned on their right side in bed and no documentation indicated the patient was repositioned on either side until the MR entry at 1735 hours indicated the patient was repositioned onto their left side in bed.

7. On 4-29-16 at 1600 hours, the administrative director of quality, staff A1, confirmed the MR for patient #1 failed to indicate the patient was repositioned off their right side from 9-27-15 at 1000 hours until 9-27-15 at 1721 hours when the patient was provided with personal hygiene.

8. The MR entry on 9-28-15 at 1348 hours by the wound and ostomy nurse, staff N4, indicated the interim development of a non-intact blister measuring 0.5 cm x 0.5 cm on the lower right buttocks and no MR documentation indicated the non-intact blister was present on admission.

9. On 4-29-16 at 1600 hours, the administrative director of quality, staff A1, confirmed the MR entry on 9-28-15 at 1348 hours indicated that an area of non-intact skin on the right buttocks was documented by the wound nurse, staff N4, and no prior documentation indicated the area of skin breakdown was present.

10. Review of the MR for patient #1 indicated on 2-17-16 that a large full thickness sacral wound was present at the time of admission.

11. The MR indicated on 2-17-16 at 1900 hours that patient #1 was resting in bed and no documentation indicated the patient was repositioned to keep pressure off the sacral wound until the MR entry on 2-18-16 at 0828 hours indicated the patient was repositioned onto their left side in bed.

12. On 4-29-16 at 1600 hours, the administrative director of quality, staff A1, confirmed the MR for patient #1 failed to indicate the patient was repositioned to keep pressure off the sacral wound from 2-17-16 at 1900 hours until 2-18-16 at 0828 hours when the MR indicated the patient was repositioned on their left side.