HospitalInspections.org

Based on record and policy review and staff interview, it was determined that the facility failed to ensure the Registered Nurse supervised and evaluated nursing care for 3 (#1, #4, #5)of 5 sampled patients. This practice does not ensure patient goals are achieved.

Findings include:

1. Patient #1's nursing documentation for restraint usage revealed that the patient was in bilateral wrist restraints from 10/11/09 - 10/15/09. Review of physician orders revealed that there was no physician order for restraint for 10/11/09 and 10/15/09. The Chief Clinical Officer (CCL) confirmed the lack of physician order during interview on 3/8/10 at approximately 1:30 p.m.

2. Review of nursing documentation for patient #1 revealed no evidence of bathing or linen change for the patient on 10/7/09, 10/11/09 and 10/22/09. The CCL confirmed the above findings during interview on 3/8/10 at approximately 1:30 p.m.

3. The facility's policy "Wound Prevention" # H WC 01-001 dated 2/07 requires that patients be turned every two hours if patient is unable to reposition self.
Patient #4 was admitted to the facility on 2/26/10. Review of nursing admission documentation revealed the patient had no pressure ulcer at the time of admission. On 3/1/10 a stage I pressure ulcer was noted on the left heel. Review of the nursing documentation revealed the following noncompliance with requirement to turn the patient every 2 hours:
On 2/28/10 at 6:02 a.m. the patient was supine. At 8:00 a.m. and 10:00 a.m. the patient refused to be turned. The notes noted the patient was supine at 12:00 p.m.. There was no evidence of the patient refusing to be turned. The patient was turned to the left side at 2:00 p.m.
On 3/04/10 there was no documentation of the patient being repositioned from 11:00 a.m. to 2:00
p.m.
On 3/06/10 there was no documentation of the patient being repositioned from 6:00 a.m. - 4:00 p.m.
The above findings were confirmed during interview with the Infection Control practitioner on 3/7/09 at approximately 9:50 a.m.

4. Patient #5 was admitted to the facility on 2/22/10. The nursing admission documentation revealed the patient had pressure ulcers on the coccyx and bilateral ankles at the time of admission. Review of the nursing documentation revealed the following noncompliance with requirement to turn the patient every 2 hours:
On 2/24/10 the patient ws in the supine position from 6:00 a.m. to 10:00 a.m. The patient was on the right side from 4:00 p.m. to 8:00 p.m..
On 2/25/10 the patient was not repositioned from 2:00 a.m. to 6:00 a.m.
On 3/01/10 the patient was not repositioned from midnight to 6:00 a.m. The patient was not repositioned from 6:00 a.m. to 10:00 a.m. The documentation noted the patient was not repositioned from 4:00 p.m. to 8:00 p.m.
On 3/05/10 the patient was supine at midnight and not repositioned until 4:00 a.m.
On 3/06/10 the patient was not repositioned from 8:00 p.m. to 2:00 a.m.
The above findings were confirmed during interview with the Infection Control Practitioner on 3/7/09 at approximately 2:58 p.m.