HospitalInspections.org

Based upon document review and interview, the Registered Nurse failed to supervise the nursing care and ensure documentation of patient repositioning every two hours was maintained for 1 of 10 medical records (MR) reviewed (Patient #4).

Findings include:

1. Review of the policy/procedure titled HIM 115 Authentication of Entries in the Medical Record (reviewed 8-20) indicated the following: "All medical record entries...must be legible, complete, [and] documents accurately the course of treatment and results..."

2. Review of the policy/procedure 1.21.06 Braden and Braden Q (Pediatric) Tool, Pressure Injury Prevention and Interventions - Four Eyes Skin Assessment (revised 7-21) indicated the following: "The Braden or Braden Q Scale is assessed: 2) with initial assessment of each shift...The Skin Bundle Assessment Order will be triggered when certain criteria are identified (Braden of 17 or lower...)...select appropriate Integumentary Interventions to meet your patient's risk level...c. Moderate Risk = 13 - 14 (i) Pressure Redistribution mattress (all beds) (ii) Turn/assist patient every two hours...chart all that apply under each category a. Integumentary interventions... c. Unable to reposition - if patient is unable to be repositioned, including microturns, indicate reason...e. Specialty bed type..."

3. Review of the MR for Patient #4 on 9-14-21 at 0800 hours indicated a Braden score of 14.

4. Review of the MR for Patient #4 on 9-14-21 from 0700 hours through 2000 hours indicated an hourly entry for the bed position described as Fowler's position or Semi (mid) Fowler's position and lacked documentation indicating the patient was repositioned, assisted with repositioning or reason if the patient was unable to be repositioned.

5. Review of the MR for Patient #4 on 9-15-21 from 0700 hours through 2000 hours indicated a 0900 hours entry indicating the mid Fowler's bed position, an 1100 hours entry indicating the patient was repositioned, a 1300 hours entry indicating the low Fowler's bed position and lacked documentation indicating the patient was repositioned, assisted with repositioning or unable at least every two hours for the day shift entries by the MS4A Supervisor N38 or Registered Nurse N39 or other nursing staff.

6. On 12-8-21 at 1400 hours, the Assistant Director of Nursing A3 confirmed the above.