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Based on policy and procedure review, medical record review, and staff interviews, facility nursing staff failed to turn patients every two hours per facility policy for 2 of 8 patients (#6 and #7).

Findings include:

Review of the named facility's nursing policy titled "Pressure Wound Prevention & Treatment Protocol", last updated 03/2016 revealed, "...Procedures 1...Patients should be assessed for potential skin breakdown based on the Braden scale (The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer and placing them at risk for skin breakdown.). Prevention measures should be initiated for inpatients with a prevailing potential for skin breakdown (Braden score <13-18). These are: A. Patients unable to turn themselves should be turned and repositioned every 2 hours...Frequent small changes in position should help prevent breakdown."

1. Review of the closed medical record on 04/27/2016 for patient #6 revealed, a 51 year old male that was admitted as an inpatient to the facility 10/24/2015 at 08:12 with recurrence of a small bowel obstruction (blockage in the small colon). The record revealed patient #6 was a bedridden quadriplegic (Paralysis caused by illness or injury that results in the partial or total loss of use of all their limbs and torso.) who also had a urinary tract infection with a supra-pubic catheter (a hollow flexible tube that is used to drain urine from the bladder), ileostomy (An ileostomy is an opening in the belly that is made during surgery. The lowest part of the small colon is brought through this opening to form an artificial opening.), and a wound vac (vacuum) (A device that uses a vacuum dressing to promote wound healing.) to a wound on the right lower leg on admission. The medical record further revealed the patient had an exploratory laparotomy with lysis of adhesions and ileostomy revision on 10/24/2015. Review of nursing documentation, dated 10/24/2015, revealed patient #6 had an initial Braden score of 14 during the admission assessment. Further review revealed subsequent Braden score assessments by the RN (Registered Nurse) ranged from 10-17 (potential for skin breakdown) throughout the patient's admission. The medical record revealed on 10/24/2015 at 08:09 patient #6 went to the operating room and returned to the medical surgical unit at 11:00. Review of nursing documentation revealed the patient was turned on 10/24/2015 at 20:00 after arrival to the medical surgical unit (9 hours later). Review of nursing documentation revealed the patient was turned on 10/25/2015 at 05:43. Review revealed the next documentation of turning was on 10/26/2015 at 22:30 (40 hours and 47 minutes later). Review of nursing documentation revealed the patient was turned on 10/27/2015 at 00:15. Review revealed the next documentation of turning was at 20:00 (19 hours and 45 minutes later). Review of nursing documentation revealed the patient was turned on 10/28/2015 at 07:30. Review revealed the next documentation of turning was at 10:29 (2 hours and 59 minutes later). Review revealed the next documentation of turning was at 20:00 (9 hours and 31 minutes later). Review of nursing documentation revealed the patient was turned on 10/29/2015 at 04:00. Review revealed the next documentation of turning was at 06:23 (2 hours and 23 minutes later). Review revealed the next documentation of turning was at 20:00 (13 hours and 37 minutes later). Review of nursing documentation revealed the patient was turned on 10/30/2015 at 06:00. Review revealed the next documentation of turning was on 10/31/2015 at 07:50 (25 hours and 50 minutes later). Review of nursing documentation revealed the patient was turned on 10/31/2015 at 15:50. Review revealed the next documentation of turning was at 18:15 (2 hours and 25 minutes later). Review of nursing documentation revealed the patient was turned on 11/02/2015 at 04:00. Review revealed the next documentation of turning was at 08:00 (4 hours later). Review of nursing documentation revealed the patient was turned on 11/02/2015 at 17:00. Review revealed the next documentation of turning was at 20:25 (3 hours and 25 minutes later). Review revealed the next documentation of turning was on 11/03/2015 at 00:05 (3 hours and 40 minutes later). Review of nursing documentation revealed the patient was turned on 11/03/2015 at 00:15. Review revealed the next documentation of turning was at 02:25 (2 hours and 10 minutes later). Review revealed the next documentation of turning was at 08:00 (5 hours and 35 minutes later). Review of nursing documentation revealed the patient was turned on 11/03/2015 at 09:00. Review revealed the next documentation of turning was at 11:53 (2 hours and 53 minutes later). Review revealed the next documentation of turning was at 15:45 (3 hours and 52 minutes later). Review revealed the next documentation of turning was at 23:14 (7 hours and 29 minutes later). Review revealed the next documentation of turning was on 11/04/2015 at 08:30 (9 hours and 16 minutes later). Review revealed the next documentation of turning was at 16:39 (8 hours and 9 minutes later). Review revealed the next documentation of turning was at 19:58 (3 hours and 19 minutes later). Review revealed the next documentation of turning was on 11/05/2015 at 06:28 (10 hours and 30 minutes later). Review revealed the next documentation of turning was at 18:25 (11 hours and 57 minutes later). Review of nursing documentation revealed the patient was turned on 11/06/2015 at 06:00. Review revealed the next documentation of turning was at 13:43 (7 hours and 43 minutes later). Review revealed there was no further documentation of turning patient #6 who was discharged on 11/08/2015 at 14:43 (49 hours). Nursing documentation revealed on 10/31/2015 at 02:37 there was a stage II (2 x 1.5 cm) PU (Pressure Ulcer (injury caused to skin when resting in a position for too long) to the coccyx (tailbone). The medical record revealed a physician order dated 11/03/2015 at 06:30 for a bariatric bed (A specialty bed that can accommodate a greater amount of weight) and another order dated 11/03/2015 at 06:31 for a zero gravity bed (A zero gravity bed is a specialty bed that simulates weightlessness and removes stress from joints. This bed can be programmed to turn patients at timed intervals.). The medical record revealed nursing documentation dated 11/03/2015 at 07:45 that there was confirmation regarding ordering this bed.

A staff interview was conducted with RN #1 on 4/26/2016 at 15:10 while touring in the CCU (Critical Care Unit). RN #1 was able to discuss the facility's turning policy and discussed the use of zero gravity beds in the CCU. RN #1 stated turning should still be documented even if the bed is programmed to turn the patient at timed intervals and pillows would still need to be repositioned at intervals to keep a patient's body in alignment and off boney prominences.

An interview was conducted on 4/27/2016 at 13:55 with Nurse Manager (NM) #1 who verified the documentation of turning in the medical record for patient #6. NM #1 verified the gaps that were observed and confirmed that this does not meet the facility's policy for turning patients every two hours who are assessed at risk for skin breakdown. The interview revealed NM #1 verified that Braden scores are to be assessed every shift by the Registered Nurse. NM #1 further revealed the Braden scale is not always assessed correctly and can be inconsistent resulting in skin breakdown risk not being identified.



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2. Review of closed medical record on 04/27/2016 for patient #7, revealed a 74 year old male that was admitted to the facility on 10/26/2015 at 1609 with a diagnosis of malnutrition (condition that develops when there is not a balance of proper food intake) bedridden and in need of total care. Review of the medical record revealed the first documented Braden score assessment was 16 upon admission. Subsequent Braden score assessments by the RN ranged from 12-16 (potential for skin breakdown) throughout the patient's admission. Review of "Daily Assessment Inquiry" revealed patient #7 was turned on 10/27/2015 at 1100 after the admission assessment (25 hours and 55 minutes since previous turning). The medical record revealed on 10/27/2015 at 1157 patient #7 had an Endoscopy (examination of the body with a flexible lighted instrument) procedure performed and was transported back to the floor at 1238. Further review revealed the patient was turned on 10/27/2015 at 0537 after returning to the floor (18 hours and 46 minutes since previous turning). Review of "Daily Assessment Inquiry" documentation revealed the patient was turned on 10/28/2015 at 0724 (25 hours and 47 minutes since previous turning). Review revealed the patient was turned on 10/29/2015 at 0724 (24 hours since previous turning). Review revealed there was no further evidence of turning patient #7 who was discharged on 10/29/2015 at 1212 (4 hours and 48 minutes later).

An interview was conducted on 04/27/2016 at 1300 with Administrator #1 who verified the failure to turn patient #7. Administrator #1 confirmed this does not meet the facility's policy for turning patients every two hours who are assessed at risk for skin breakdown.
NC00116267