HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 4 patients (Pt #1) reviewed for pressure ulcer care, the Hospital failed to ensure that Pt #1 was turned or repositioned every 2 hours, as ordered.

Findings include:

1. On 7/13/2020, Pt #1's clinical record was reviewed and indicated:

-Pt #1's admission assessment dated 10/7/2019 indicated "Braden Score total -15" (high risk for pressure ulcer).

-P#1's history and physical dated 10/8/2019 indicated "Admission date & time (10/7/2019 at 3:10 PM)... Pt #1 admitted from inpatient rehab due to fever and acute renal failure. Pt #1 had temp of 102 with unknown cause..."

-Pt #1's physician orders, dated 10/8/2019, included, "...Activity: Reposition every 2 hours..."

Pt #1's surgical consult note, dated 10/9/2019, included, "reason for encounter - sacral wound...surgery was consulted for necrotic sacral wound...sacral wound necrotic without any significant drainage..."

-Pt #1's Wound Care Nurses' notes indicated the following:
- 10/8/2019 -Pt #1 having difficulty with positioning self. Turn every 2 hours and float heels. Unstageable Pressure Injury on sacrum/coccyx- measurement (12.5 length x 4.5 width x 3.4 depth) ...Recommend surgical evaluation for sacral wound and possible debridement ..."
-10/14/2019 - Pt #1 is severely obese and unable to turn self. Pt #1 is incontinent of large amount stool which is in wound bed. Turn every 2 hours. Stage 4 pressure injury - sacrum - measurement (13.5 length x 8 width x 6 depth)
-10/22/2019 - Stage 4 pressure injury -sacrum - measurements (12.5 length x 8 width x 5.8 depth)
-10/28/2019 - Stage 4 pressure injury - sacrum - measurements (12.5 length x 7 width x 2.8 depth)

-Pt #1's operative report, dated 10/11/2019, included "Preoperative diagnosis: Necrotic sacral wound - Excisional debridement of skin and soft tissue from sacral wound (10 x 9 cm) 3 cm depth ..."

-Pt #1's Rounding Flow Sheets dated 10/10/2019 through 10/28/2019 indicated:

-10/10/2019 - 4:15 PM - Pt #1 turned on back and 10:00 PM - Pt #1 moved up in bed
-10/11/2019 - 10:00 PM - Pt #1 moved up in bed
-10/12/2019 - 2:00 AM & 2:00 PM - Pt #1 moved up in bed, 10:00 PM - Pt #1 turned on right side
-10/13/2019 - 2:00 AM - Pt #1 turned on right side, 9:10 AM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/14/2019 - 2:07 AM - Pt #1 turned on back, 10:00 AM - Pt #1 turned on right side, 2:00 PM - Pt #1 moved up in bed
-10/15/2019 - 2:16 AM - Pt #1 moved up in bed, 10:00 AM - Pt #1 turned on right side, 2:00 PM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/16/2019 - 2:00 AM - Pt #1 turned on right side
-10/17/2019 - 12:00 AM - Pt #1 turned on left side, 2:13 AM - Pt #1 turned on right side, 5:02 AM - Pt #1 turned on back, 10:00 PM - Pt #1 turned on back
-10/18/2019 - 2:00 AM - Pt #1 turned on left side, 10:00 AM - Pt #1 turned on right side
-10/19/2019 - 10:00 AM - Pt #1 moved up in bed, 2:00 PM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/20/2019 - 1:59 AM - Pt #1 turned on back, 6:00 AM - Pt #1 moved up in bed, 10:00 AM- Pt #1 turned on left side, 2:00 PM - Pt #1 turned on right side
-10/21/2019 - 10:00 AM - Pt #1 turned on back, 2:00 PM - Pt #1 turned on right side
-10/22/2019 - 8:59 AM - Pt #1 turned on left side, 10:50 AM - Pt #1 turned on back, 12:25 PM - Pt #1 turned on left side, 2:30 PM - Pt #1 turned on right side, 4:20 PM - Pt #1 turned on right side, 6:13 PM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/23/2019 - 2:00 AM - Pt #1 turned on back, 10:00 AM - Pt #1 turned on back, 2:00 PM - Pt #1 moved up in bed
-10/24/2019 - 2:00 AM - Pt #1 turned on right side, 10:00 PM - Pt #1 turned on left side
-10/25/2019 - 2:00 AM - Pt #1 turned on right side, 10:00 PM - Pt #1 turned on back
-10/26/2019 - 2:00 AM - Pt #1 turned on right side, 10:00 AM - Pt #1 turned on right side
-10/28/2019 - 10:00 AM - Pt #1 turned on right side, 2:00 PM - Pt #1 turned on left side

Pt #1's Rounding Flow Sheets, dated 10/10/2019 through 10/28/2019, lacked documentation of repositioning/turning every 2 hours, as ordered.

2. On 7/14/2020 at 8:45 AM, an interview was conducted with the Manager of Risk Management/Clinical Excellence (E #2). E #2 stated that the Hospital does not have a wound policy or protocol regarding repositioning. E #2 stated that this has been identified as a problem, and the Hospital is in the process of putting a protocol in place.

3. On 7/14/2020 at 9:00 AM, an interview was conducted with the Director of Risk Management (E #3). E #3 stated that there is no policy/protocol for turning patients with pressure ulcers. E #3 stated that the nurses on the units should follow the physicians' orders. E #3 stated that if a patient needs to be turned, they turn the patient.

4. On 7/15/2020 at 1:15 PM, an interview was conducted with the Attending Physician (MD #1). MD #1 stated that Pt #1's order was to reposition Pt #1 every 2 hours. MD #1 stated that staff should always try to reposition a patient every 2 hours when it is ordered. MD #1 stated that Pt #1 was very large and needed help repositioning/turning.

B. Based on document review and interview, it was determined that for 2 of 2 Registered Nurses (E #4 & E #5), the Hospital failed to ensure pressure ulcer assessment and care training was provided.

Findings include:

1. On 7/15/2020, the Hospital was not able to provide a training module for pressure ulcer assessment and care.

2. On 7/15/2020, the Hospital's Competencies 2019 list was reviewed and indicated that pressure ulcer assessment and care was not included in the training.

3. On 7/15/2020, the Registered Nurses' (E #4 & E #5) employee files were reviewed for pressure ulcer assessment and care training. There was no documentation in E #4 or E #5's employee file regarding any pressure ulcer assessment or care training.

4. On 7/15/2020 at 11:30 AM, an interview was conducted with the Nurse Educator (E #7). E #7 stated that annual competencies are completed for each nurse. E #6 stated that pressure ulcer assessment and care was not on the 2019 competencies but will be included in the 2020 competencies for nurses.