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Based on policy review, medical record reviews and charge nurse interview, the hospital nursing staff failed to ensure patients assessed as high risk for pressure ulcer development had documented Pressure Ulcer Prevention interventions per the hospital's policy for 2 of 2 patients with a Stage II pressure ulcer (#8 and #7).

Findings include:

Review of current hospital policy "Pressure Ulcer Prevention" approval date 03/20/2013, revealed "(Name of hospital) is committed to provide a comprehensive pressure ulcer prevention program to all patients in order to reduce the risk of pressure ulcer development and provide appropriate and effective treatment through evidenced based practices. . . 1. Nursing Actions for 'At Risk' Category: Patients with Braden score of 18 or below without pressure ulcers present on admission. . . K - Keep Patients Turning. Reposition patient every two hours and maximize mobilization. . . DOCUMENT ALL INTERVENTIONS"

1. Open medical record review for Patient #8 revealed a hospital admission on 12/11/2014 with diagnoses of pneumonia and congestive heart failure. Review of nursing "Pressure Ulcer Risk Assessment" conducted twice per day from 12/11/2014 through 12/18/2014, revealed the patient was scored an "18 or below at Risk" at each assessment. Continued review of nursing assessments revealed the patient entered the hospital on 12/11/2014 with a "Left Buttock . . . 2CM x 2CM, red. No drainage . . . Stage II" pressure ulcer. Continued review revealed the wound assessment for 12/18/2014 at 0820, discharge assessment, "2 cm skin tear to left buttock with redness noted . . . Stage II" pressure ulcer. Review of nursing assessment for Mobility and Activity from 12/11/2014 through 12/18/2014 revealed the patient was assessed two times per day for "Mobility" as "Very Limited" and "Activity" as "Bedfast." Review of "Patient Care Management Profile" implemented 12/11/2014 revealed 'Braden Scale, Skin and Wound Care Q shift [every shift]" and "Toilet and Reposition Q 2 HOURS" Review of Nursing Progress Notes and CNA Worksheet notes from 12/11/2014 at 0612 through 12/18/2014 at 1400 revealed no documentation the patient was turned every two hours to promote healing of existing pressure ulcer or prevent pressure ulcer development.

Interview with Employee #5, a registered nurse, on 12/17/2014 at 0935 revealed Turning and Repositioning documentation was expected to be located on the CNA Worksheet or Nursing Progress Notes. Employee #5 stated the RN is responsible for CNA supervision to ensure tasks are completed as directed. Employee #5 stated documentation was incomplete to support Patient #8 was turned/repositioned as directed to prevent pressure ulcer development.

2. Closed record review for Patient #7 revealed a hospital admission on 10/08/2014, after a physician office visit, due to chronic left lower extremity pain, diabetes and end stage renal disease. Review of nursing "Pressure Ulcer Risk Assessment" conducted twice per day 10/09/2014 through 10/29/2014, revealed the patient was scored an "18 or below at Risk" at each assessment. Continued nursing assessment review revealed no skin breakdown of buttocks documented until 10/16/2014 at 1845 which stated "3CM x 2CM OPENING ON DISTAL LEFT BUTTOCK, PINK NO ODOR AND 2CM X 1CM LEFT POSTERIOR BUTTOCKS." Review of nursing assessment for Mobility and Activity for 10/09/2014 through 10/29/2014 revealed the patient was assessed two times per day as "Complete Immobile" and "Bedfast." Review of "Patient Care Management Profile" (patient care plan) implemented 10/08/2014 revealed 'Braden Scale, Skin and Wound Care Q shift [every shift]" and "CNA [certified nursing assistant]: Shift Assessment, turn Q2 Bedrest." Review of nursing progress notes and CNA Worksheet notes for 10/09/2014 at 0035 through discharge on 10/29/2014 at 1322 revealed no documentation the patient was "Turned/Repositioned" every two hours to prevent pressure ulcer development.

Interview with Employee #5, a registered nurse, on 12/17/2014 at 0935 revealed Turning and Repositioning documentation was expected to be located on the CNA Worksheet or Nursing Progress Notes. Employee #5 stated the RN is responsible for CNA supervision to ensure tasks are completed as directed. Employee #5 stated documentation was incomplete to support Patient #7 was turned/repositioned as directed to prevent pressure ulcer development.

NC00101732

Based on hospital policy review, medical record review and staff interview, the hospital nursing staff failed to ensure discharge instructions were complete for use of durable medical equipment for 1 of 2 patients discharged with durable medical equipment (#6) .

Findings include:

Review of hospital policy "Discharge of Patients" approval date 11/27/2013, revealed "Physician orders the discharge and completes the Discharge Instruction Sheet which includes: medications, special referrals, outpatient tests/procedures, follow-up instructions. The Discharge Instruction Sheet must be completed and signed by the discharging RN, discharging physician, and patient/family. . . The discharging nurse/case manager/social worker completes all community resource referrals/DME's [durable medical equipment] and documents these on the Discharge Instruction Sheet."

Closed medical record review for Patient #6 revealed a hospital admission via the emergency department on 11/25/2014 with diagnoses including a left wrist fracture, sternal fracture, left knee pain and irregular heartbeat following a motor vehicle crash. Review of physician's orders revealed an order for "immobilizer to L knee . . . wrist splint to L wrist" written on 11/25/2014 at 2015 and noted by nursing staff 11/25/2014 at 2120. Review of Nursing Progress notes 11/25/2014 through discharge on 12/03/2014 revealed a knee immobilizer to left knee and a wrist splint to left wrist was maintained throughout hospitalization. Review of discharge instructions dated 12/03/2014 at 1642 revealed Nursing Check List
did not include instructions when to apply or remove the knee immobilzer or wrist splint

Further review revealed "Devices Placed Info Given 12/3/2014 16:24:34 NA [not applicable]" There was no evidence the discharge instructions were complete for the inclusion of when to apply or remove the knee immobilizer or wrist restraint.

Interview with Employee #9, a case manager, on 12/17/2014 at 1210 revealed all durable medical equipment a patient will use at home, including a knee immobilizer and wrist splint, should be included with the discharge plan instructions. Employee #9 stated the discharge instructions for Patient #6 were incomplete.

NC00102731