HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that patients were turned and repositioned at least every two hours and as needed in two of six medical records reviewed (Patient (P)2 and P4).

Findings include:

Policy titled, "Skin and Wound Care: Risk for or Impaired Skin Integrity-Assessment, Pressure Injury Staging, Prevention & Treatment Recommendations" last Reviewed, 4/24/2024, stated, "... Nursing Documentation 1. Document preventative measures taken ... Recommended Pressure Injury Prevention Strategies Based on Risk Factors (unless contraindicated) ... Mobility ... Reposition and turn at least every 2 hours or based on individualized schedule as appropriate per the assessed needs/condition of the patient. .... Attachment C: Skin Bundle Checklist Recommendations ... B ... Document Q2hr [every two hours] repositioning."

Policy titled, "Skin and Wound Care: Risk for or Impaired Skin Integrity-Assessment, Pressure Injury Staging, Prevention & Treatment Recommendations" last Reviewed, 4/24/2024, stated, "... Nursing Interventions: 1. Initiate Interdisciplinary Plan of Care upon admission. Review daily and revise as needed ... Nursing Documentation 1. Document preventative measures taken and any changes made to the interdisciplinary care plan base on the ongoing assessments of the patient's needs and risk factors... Attachment C: Skin Bundle Checklist Recommendations... Braden
On 08/05/25 at 10:25 AM, an interview was conducted with Staff (S)8. When asked how often a patient is turned and repositioned, S8 stated, he/she uses her judgement and if the Braden Score (Pressure Injury Risk Assessment, Not at Risk 19 or above, At Risk 15-18, Moderate Risk 13-14, High Risk 10-12, Very High Risk 9 or below) is less than 18 or if a patient cannot turn themselves, he/she would turn the patient every two hours and document every two hour turns in EPIC (electronic medical record system). When asked what communication is in place to make staff members aware of the patient's need to be repositioned every two hours, S8 stated, he/she would look at the patient and see what position they are in then turn them the other way. S8 further stated, he/she can look in the chart to see the patient's last position. S8 stated, "everyone is pretty good at charting turns." S8 stated, he/she gets report from the previous nurse and the patient's position will be discussed then. In addition, S8 stated that patients have the leaf system [a sensor placed on the patient's chest that constantly monitors the patients position and activity] and there is a reminder on the monitor that turns red when it is time to turn the patient.

At 10:46 AM, an interview was conducted with S10. When asked how often a patient is turned and/or repositioned, S10 stated, "every two hours and as needed, if the patient turns self and has a Braden score of 19 or more then every two-hour turns are not required." When asked how staff communicates with each other to ensure the patient is being turned every two hours, S10 explained, Nursing and PCTs (patient care technicians) get report at the beginning of the shift and that is when they will discuss the patients positioning."

At 11:01 AM, an interview was conducted with S11. When asked how often patients are turned and/or repositioned, S11 stated, "every two hours. There is the leaf system on a lot of floors and a chart outside of the room that staff signs off that the patient was turned, and the turns are documented in EPIC [electronic medical record system]."

On 8/6/2025 a review of P2's medical record was conducted in the presence of S17 and S45 and revealed the following:

P2 was admitted on 8/5/2025 with a UTI (urinary tract infection). P2 had a stage 2 pressure injury to the coccyx/sacrum area on admission. P2 Braden Score was 17.

On 8/5/2025 at 2:52 PM, a wound care consultation note, documented by S46 stated, "... Other recommendations as appropriate for the patient: Offload/Reposition in bed Q [every]1-2 hours."

On 8/5/2025 at 2:47 AM, documentation in the flowsheets titled, "Mobility" stated, "... Early Mobility Protocol Level Initiated/Maintained: Bed rest advance as tolerated. Activity: Bedrest Level of Assistance: Maximum assist, patient does 25-49% Patient Position: Supine Pillow Support, positioning frequency: every 2 hours."

On 8/5/2025 at 11:25 AM, documentation in the flowsheets titled, "Mobility" stated, "... Early Mobility Protocol Level Initiated/Maintained: Ambulation with assistance. Activity: Chair Level of Assistance: Moderate assist, patient does 50-74%, Mobility Assistive Device: Walker, Ambulation Response: Tolerated Poorly, Patient Position: Supine, Positioning frequency: every 2 hours."

The medical record lacks evidence of P2 being turned every two hours.

On 8/6/2025 at 11:58 AM, when asked if every two-hour turning should be documented in the flowsheets, S45 stated, "yes, there shouldn't be gaps in the documentation."

On 8/6/2025 a review of P4's medical record was conducted in the presence of S45 and revealed the following:

P4 was admitted on 8/4/2025 with abnormal labs. P4 had a Stage 3 pressure injury to the buttocks and DTI (deep tissue injury) to right heel and bilateral toe tips on admission. P4's Braden Score was 14.

On 8/5/2025 at 2:52 PM, a consultation note, documented by S46 stated, "... Other recommendations as appropriate for the patient: Offload/Reposition in bed Q [every]1-2 hours."

On 8/4/2025 at 10:52 PM, documentation in the flowsheets titled, "Mobility" stated, "...Patient Position: Lying right side; Semi Fowler's Pillow Support."

On 8/5/2025 at 9:29 AM, documentation in the flowsheets titled, "Mobility" stated, "Early Mobility Protocol Level Initiated/Maintained: Bed rest advance as tolerated. Activity: Bedrest."

The medical record lacked documented evidence that P4 was turned every two hours.

On 8/6/25 at 12:57 PM, S45 confirmed that P4 should have been repositioned per the consultation recommendations and the facility's policy.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that 1) Nursing staff initiated a skin integrity care plan in five of six medical records reviewed (Patient (P)2, MP3, P4, P5, and P6); and 2) patients were turned and repositioned at least every two hours in two of six medical records reviewed (P2 and P4).

Findings include:

1. Facility Policy titled, "Plan of Care, Interdisciplinary" last reviewed on 3/27/2024, stated, "... III. Policy A. All admitted patients will have a plan of care initiated that is individualized for their specific care needs and limitations.... The Plan of Care will be initiated by Nursing ... The plan of care will reflect the patient's health problems, specific goals of therapy, and will detail strategies to achieve goals."

Facility Policy titled, "Skin and Wound Care: Risk for or Impaired Skin Integrity-Assessment, Pressure Injury Staging, Prevention & Treatment Recommendations" last Reviewed, 4/24/2024, stated, "... Nursing Interventions: 1. Initiate Interdisciplinary Plan of Care upon admission. Review daily and revise as needed... Nursing Documentation 1. Document preventative measures taken and any changes made to the interdisciplinary care plan base on the ongoing assessments of the patient's needs and risk factors... Attachment C: Skin Bundle Checklist Recommendations... Braden
On 8/6/2025, a review of P2's medical record was conducted in the presence of Staff (S)17 and S45 and revealed the following:

P2 was admitted on 8/5/2025 with a UTI (urinary tract infection). P2 had a Stage 2 pressure injury to the coccyx/sacrum area on admission. P2's Braden Score was 17.

On 8/5/2025, at 2:52 PM, P2 was seen by wound care.

The medical record of P2 lacked documented evidence of a Skin Integrity Care Plan.

On 8/6/2025 at 11:58 AM, when asked if the patient's medical record should contain a Skin Integrity care plan, S45 stated, "yes, there should be a skin care plan."

On 8/6/202, a review of P3's medical record was conducted in the presence of S45 and revealed the following:

P3 was admitted on 8/3/2025 with weakness. P3 had a Stage 2 pressure injury to left buttock, a Stage 1 pressure injury to the left heel on admission. P3's Brade Score was 15.

On 8/4/2025 at 2:00 PM, P3 was seen by wound care.

P3's medical record lacked evidence of a Skin Integrity Care Plan.

On 8/6/2025, a review of P4's medical record was conducted in the presence of S45 and revealed the following:

P4 was admitted on 8/4/2025 with abnormal labs. P4 had a Stage 3 pressure injury to the buttocks and DTI (deep tissue injury) to right heel and bilateral toe tips on admission. P4's Braden Score was 14.

On 8/5/2025 at 2:52 PM, P4 was seen by wound care.

P4's medical record lacked evidence of a Skin Integrity Care Plan.

The above findings were confirmed with S45 on 8/6/2025 at 12:07 PM.

On 8/6/2025 a review of P5's medical record was conducted in the presence of S45 and revealed the following:

On 8/4/2025, P5 was admitted with left shoulder injury. P5 had a Stage 2 pressure injury to right buttocks and possible DTI to left heel on admission. P5's Braden Score was 16.

On 8/4/2025 at 2:00 PM, P5 was seen by wound care.

P5's medical record lacked evidence of a Skin Integrity Care Plan.

On 8/6/2025 a review of P6's medical record was conducted in the presence of S45 and revealed the following:

On 7/31/2025, P6 was admitted with altered mental status. P6 had a Stage 2 pressure injury to coccyx/natal cleft area on admission. P6's Braden score was 14.

On 8/1/2025 at 1:31 PM, P6 was seen by wound care.

P6's medical record lacked documented evidence of a Skin Integrity Care Plan.

The above findings confirmed with S45 on 8/6/2025 at 12:57 PM.