HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) records reviewed for turning/repositioning, the Hospital failed to ensure that nursing care was provided to turn patients at least every 2 hours as required to prevent skin breakdown.

Findings include:

1. The Hospital's policy titled, "Routine Care and Pressure Ulcer Prevention" (revised 3/8/2022), was reviewed and required, "...Change position of patient every 2 hours if bed bound..."

2. The clinical record for Pt. #1 was reviewed on 04/22/2024. Pt. #1 was admitted on 1/30/2024 at 7:03 PM, with a diagnoses of acute on chronic hypoxic respiratory failure requiring mechanical ventilation, cachexia (extreme weight loss/muscle wasting), recent sepsis secondary to multifocal pneumonia and catheter related UTI (urinary tract infection), and stage 4 sacral decubiti and right leg wound present on admission. Nursing assessments on admission (1/30/2024) indicated that Pt. #1 was at risk for pressure injuries with a Braden score of 12 (scores less than 18 = at risk). Pt. #1 was noted to be completely dependent for ambulation, transferring, toileting, bathing, dressing, and eating and had difficulty with communication and swallowing. Physician's orders to turn the patient every 2 hours were placed on 1/31/2024 at 2:36 PM. Nursing flowsheets from 2/1/2024-2/14/2024 were reviewed for repositioning and lacked documentation that Pt. #1 was turned minimally every 2 hours as required between the following times:
- 2/1/2024: Pt. #1 documented in supine position from 12:00 AM until 7:47 PM.
- 2/2/2024 from 2:00 AM to 8:00 AM (6 hour lapse).
- From 2/2/2024 at 8:00 PM to 2/3/2024 at 2:00 AM (6 hour lapse).
- From 2/3/2024 at 8:00 PM to 2/4/2024 at 8:00 AM, Pt. #1 documented in supine position.
- 2/5/2024 from 2:00 AM to 6:30 AM with no documented repositioning. Nurses note at 6:30 AM included that a new wound was found to the sacral area.
- From 2/5/2024 at 8:40 PM to 2/6/2024 at 2:00 AM (5+ hours lapse).
- 2/6/2024: Pt. #1 documented in supine position from 6:00 AM to 10:00 AM (~4 hours).
- From 2/6/2024 at 7:35 PM to 2/7/2024 at 7:45 AM with no documented repositioning.
- From 2/7/2024 8:00 PM to 2/8/2024 at 1:54 AM (~6 hour lapse).
- 2/8/2024 from 1:54 AM to 6:00 AM (~4 hour lapse).
- From 2/10/2024 at 6:00 PM to 2/11/2024 at 3:06 AM (~9 hour lapse).
- 2/11/2024 from 3:06 AM to 7:10 AM (~4 hour lapse).
- The record lacked documentation why Pt. #1 was not repositioned during these periods (i.e. if the patient refused).

3. On 4/22/2024 at 11:05 AM, an interview was conducted with the Registered Nurse (E #4). E #4 stated that all patients are turned every 2 hours. E #4 stated that there is a clock in the nursing station with the position patients should be turned to every 2 hours.


B. Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) records reviewed for nutrition management, the Hospital failed to ensure that nursing care provided nutritional supplements as ordered for patients at risk for skin breakdown/pressure ulcer development.

Findings include:

1. The Hospital's policy titled, "Routine Care and Pressure Ulcer Prevention" (revised 3/8/2022), was reviewed and required, "...Nutrition: ....Maintain adequate nutrition (balanced nutritional intake and supplements)... Document assessment and interventions..."

2. The Hospital's Policy titled, "Parenteral/Enteral Products: Responsibilities for Handling" (revised 6/2020), was reviewed and required, "...Type of Product: Supplement... Department: Nursing... Responsibility: Patient administration..."

3. The clinical record for Pt. #1 was reviewed on 04/22/2024. Pt. #1 was admitted on 1/30/2024 at 7:03 PM, with a diagnoses of acute on chronic hypoxic respiratory failure requiring mechanical ventilation, cachexia (extreme weight loss/muscle wasting), recent sepsis secondary to multifocal pneumonia and catheter related UTI (urinary tract infection), and stage 4 sacral decubiti and right leg wound present on admission. Nursing assessments on admission (1/30/2024) indicated that Pt. #1 was at risk for pressure injuries with a Braden score of 12 (scores less than 18 = at risk). Pt. #1 was noted to be completely dependent for ambulation, transferring, toileting, bathing, dressing, and eating and had difficulty with communication and swallowing. Physician's orders to administer Juven Supplement Packet twice a day were placed on 2/1/2024, at 10:00 AM and continued until discharge on 2/24/2024. Nursing records from 2/1/2024-2/24/2024 were reviewed and lacked documentation that the supplements were administered as ordered on the following dates:
- Only 1 packet administered (instead of 2 per day as ordered) on 2/2/2024-2/4/2024, 2/6/2024, 2/8/2024, 2/9/2024, 2/12/2024-2/14/2024, and 2/20/2024-2/21/2024.
- No supplement administrations were documented on 2/7/2024 and 2/15/2024.
- The record did not include documentation as to why the supplements were not administered on these dates.

4. An interview was conducted with the Charge Nurse of 2 South (E#6) on 4/24/2024, at approximately 9:00 AM. E#6 stated that the nurses are responsible for administering any ordered supplements. E#6 stated that the nurse should document in the record if and when the supplement was administered or document a reason why the supplement was not given.