HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the care provided was documented in the medical record for 1 (P[patient]2) out of 20 (P1-P20) patients medical records reviewed. This deficient practice could lead to inaccuracy of the medical record.

The findings are:

A. Record review of P2's medical record for the admission date 04/30/2025 revealed the following:

1. Under "Orders" there is an order to reposition patient every 2 hours dated, 04/30/2025 that stated "q2h [every 2 hour] turns, off load buttocks [change position to keep pressure off the bottom], keep HOB [head of bed] less than 30 degrees, float heels [elevate heels off the bed to reduce pressure]."

2. Under "Activities of Daily Living" it was documented "Reposition every 2 hours" from 05/02/2025 through 05/06/2025. There was no evidence that the patient was turned to off load pressure from the bottom nor was it documented that patients heels were floated.

B. During an interview on 05/08/2025 at 9:00 AM with S (staff) 1 non-clinical, it was confirmed that the positioning activity was not documented.