HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined facility failed to ensure the turning and repositioning of patients at risk for pressure injury was accurately documented in three of three medical records reviewed (MR1, MR6 and MR7), as nursing staff were permitted to document the nursing care provided in the past four hours or the nursing care that would be provided in the future four hours.

Findings include:

Review on April 20, 2017, of the facility policy "Guidelines for Prevention of Pressure Injuries," revised February 2017, revealed "Policy: If a patient is identified as being at risk for pressure injuries, specific preventative measures will be implemented according to individual risk factors, (e.g. initiate measures to assist with mobility/activity). Purpose: To implement specific nursing strategies of pressure injury prevention in patients at risk for skin breakdown. Scope: All patients identified to be at risk for pressure injuries. Procedure: ... Measures To Assist With Mobility/Activity And Friction/Shear Issues: 1. Institute proper positioning, transferring and turning techniques, based on individual patient needs. Reposition the bedfast patient at least every 2 hours. ..."

Review on April 20, 2017, of the facility policy "Pressure Injuries Treatment Guidelines," revised February 2017, revealed "Policy: Pressure injuries are a serious problem for patients, families and the Healthcare team. Correct Management of patients with pressure injuries is based on scientific evidence and is an important consideration in caring for this population. Purpose: To provide evidence based guidelines for the care and treatment of pressure injuries. Scope: All patients with pressure injuries. Procedure: ... Pressure Injury Definition: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can be present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. ... Turn or reposition every 2 hours, every hour if in chair. ... "

The Department received a concern that a patient was not turned and repositioned, resulting in a pressure wound.

Review of MR1 on April 20, 2017, revealed the patient was admitted to the facility on February 7, 2017. Nursing completed a Braden Scale pressure sore assessment and determined the patient's score was 17 and was at risk for developing pressure sores. Nursing developed MR1's individual plan of care and treatment on February 7, 2017, which include impaired mobility and actual problem with skin integrity and instructions for staff to follow to prevent pressure sores. These instructions included turning, repositioning and changing MR1's position every 2 hours.

Nursing documented revealed MR1 was turned and repositioned every 2 hours as follows:
February 8, 2017, at 4:03 AM, 7:57 AM and 3:35 PM
February 9, 2017, at 1:00 AM, 7:00 AM and 4:00 PM
February 10, 2017, at 2:23 AM, 7:37 AM and 4:06 PM
February 11, 2017, at 0:47 AM, 8:23 AM and 6:22 PM
February 12, 2017, at 0:35 AM and 12:24 PM
February 13, 2017, at 3:56 AM and 7:27 AM.

Interview with EMP6 on February 20, 2017, at approximately 11:30 AM confirmed MR1 was admitted to the facility on February 7, 2017; nursing completed a Braden Scale pressure sore assessment and determined the patient's score was 17 and was at risk for developing pressure sores; MR1's individual plan of care and treatment included impaired mobility and actual problem with skin integrity and instructions for staff to follow to prevent pressure sores; and these instructions included turning, repositioning and changing MR1's position every 2 hours. EMP6 confirmed the times noted above that nursing staff documented MR1's turning and repositioning, and the times did not reflect turning and repositioning every two hours.

Review of MR6 on April 20, 2017, revealed the patient was admitted to the facility on February 12, 2017. Nursing completed a Braden Scale pressure sore assessment and determined the patient's score was 18 and was at risk for developing pressure sores. Nursing developed MR6's individual plan of care and treatment on February 12, 2017, which included impaired mobility and actual problem with skin integrity and instructions for staff to follow to prevent pressure sores. These instructions included turning, repositioning and changing MR6's position every 2 hours.

Nursing documented MR6 was turned and repositioned every 2 hours as follows:
February 12, 2017, at 9:30 PM
February 13, 2017, at 00:00 AM, 8:14 AM and 4:31 PM
February 14, 2017, at 7:50 AM
February 15, 2017, at 0:40 AM, 7:43 AM and 4:00 PM
February 16, 2017, at 00:00 AM, 7:42 AM, 7:54 AM and 6:23 PM
February 17, 2017, at 0:15 AM and 7:30 AM.

Interview with EMP6 on February 20, 2017, at approximately 11:45 AM confirmed MR6 was admitted to the facility on February 12, 2017; nursing completed a Braden Scale pressure sore assessment and determined the patient's score was 18 and was at risk for developing pressure sores; MR6's individual plan of care and treatment included impaired mobility and actual problem with skin integrity and instructions for staff to follow to prevent pressure sores; and these instructions included turning, repositioning and changing MR6's position every 2 hours. EMP6 confirmed the times nursing staff documented MR6's turning and repositioning, noted above, and the times did not reflect turning and repositioning every two hours.

Review of MR7 on April 20, 2017, revealed the patient was admitted to the facility on February 15, 2017, and nursing completed a Braden Scale pressure sore assessment and determined the patient's score was 18 and was at risk for developing pressure sores. Nursing developed MR7's individual plan of care and treatment on February 15, 2017, which included impaired mobility and actual problem with skin integrity and instructions for staff to follow to prevent pressure sores. These instructions included turning, repositioning and changing MR7's position every 2 hours.

Nursing documented MR7 was turned and repositioned every 2 hours as follows:
February 15, 2017, at 8:30 AM and 4:01 PM
February 16, 2017, at 00:50 AM, 9:00 AM and 3:55 PM
February 17, 2017, at 0:13 AM.

Interview with EMP6 on February 20, 2017, at approximately 11:55 AM confirmed MR7 was admitted to the facility on February 15, 2017; nursing completed a Braden Scale pressure sore assessment and determined the patient's score was 18 and was at risk for developing pressure sores; MR7's individual plan of care and treatment included impaired mobility and actual problem with skin integrity and instructions for staff to follow to prevent pressure sores; and these instructions included turning, repositioning and changing MR7's position every 2 hours. EMP6 confirmed the times nursing staff documented MR7's turning and repositioning, as noted above; and the times did not reflect turning and repositioning every two hours.

Interview on April 20, 2017, with EMP7 at approximately 1:30 PM revealed it was not facility practice to document a patient's turning and repositioning every two hours as that was not practical. EMP7 stated the nursing documentation completed in the medical record every four hours reflected the nursing care provided in the past four hours or the nursing care that would be provided in the future four hours.

Interview with EMP6 on April 20, 2017, at 1:35 PM confirmed the process of future documentation was a pattern for how nursing documents in the patient medical records at the facility.