HospitalInspections.org

Based on record review and interviews, the facility failed to ensure that the Registered Nurses (RNs) supervised and evaluated the nursing care on an ongoing basis in accordance with accepted standards of nursing practice for turning and repositioning every 2 hours and the prevention and development of pressure injuries to the left buttock and right heel for 1 out of 4 Sampled Patients (SP). SP#1

Findings include:

Review of the Initial Risk Management note documented SP#1 was admitted on 04/28/2020. Present on admission no pressure injury indicated.

Interview with Staff E (Chief Nursing Officer) on 05/31/2022 at 1:15 PM confirmed that if a wound was present on admission, it should have been documented.

Interview with the Nursing Director of 4-North on 06/01/2022 at 12:10 PM revealed that when the Braden Scale Assessment score is documented in the electronic medical record if less than 18, the system triggers nursing interventions (care plan) to be initiated for the Pressure Injury Prevention Protocol (a standing order contained within the Wound Care Order Set).

Review of the Braden Scale Assessment for SP#1 documented:

04/28/2020 at 11:27 PM: Braden Scale Score = 18 (Admission)
04/30/2020 at 9:00 AM: Braden Scale Score=15
05/15/2020 at 8:30 AM Braden Scale Score=11
05/16/2020 at 8:30 AM Braden Scale Score=11
05/18/2020 at 8:37 AM Braden Scale Score=12
05/20/2020 at 8:00 AM Braden Scale Score=12

Review of the Pressure Prevention Flowsheet Peel Back Assessment documented:

05/15/2020 at 8:39 PM: Skin Intact, Redness
05/16/2020 at 8:49 PM: Skin Intact, Redness
05/18/2020 at 8:37 AM: Redness
05/20/2020 at 8:34 PM: Redness
05/21/2020 at 7:30 PM: Deep Tissue Injury (DTI)

Review of the Turning/Repositioning Flowsheets documented:

05/15/2020: SP#1 lying in supine position. Not repositioned for nearly 12 hours.

05/16/2020: SP#1 lying in supine position. Not repositioned for nearly 7 hours.

05/18/2020: SP#1 in bed, position not documented. Not repositioned for nearly 16 hours.

05/19/2020: SP#1 in bed, position not documented. Not repositioned for nearly 8 hours.

Further record review revealed SP#1 developed a hospital acquired pressure injury (HAPI) on 05/20/2020 that progressed to an unstageable wound on the left buttock.

Review of the Braden Scale scores for SP#1 documented between 04/28/2020 and 05/20/2020 range from 18 - 11. Review of the Wound Care Order Set included Implementation of Pressure Injury Prevention Protocol activities:

Dressing type: Foam adhesive dressing.
Action: Relieve pressure. Turn every 2 hours. Keep skin clean and dry. Apply moisture barrier, off load heels at all times - one pillow per leg vertically. Head of bed 30 degrees or less if not contraindicated. Lift using draw sheet. Turning 30 degrees every 2 hours. Use turning Device Wedge.

Interview with the Patient Safety Director (also responsible for Quality Assurance Performance Improvement (QAPI) activities in the hospital) on 05/31/2022 at 11:35 AM revealed Pressure Injury development; Body Part: Butt; Body Side: Left.

The facility failed to provide nursing care and services to meet the needs of SP#1 for turning and repositioning every 2 hours and the development of pressure injuries.