HospitalInspections.org

Based on hospital policy review, open medical record review and physician and staff interview, the facility staff failed to ensure a patient was turned every 2 hours as ordered to prevent a decubitus for 1 of 1 patients (#7).

The findings include:

Review of Mosby Nursing Skills titled "Pressure Ulcer: Risk Assessment and Prevention", copyright 2006-2016 Elsevier Inc., "Clinical Skills" revealed "... Perform a skin assessment within 2 hours and document findings in the EMR (Electronic Medical Record) within 8 hours of a hospital admission... SKIN/WOUND BEST PRACTICES: -Conduct a complete skin assessment every shift on every patient..."

Review of Mosby Nursing Skills titled "Pressure Ulcer: Risk Assessment and Prevention", copyright 2006-2016 Elsevier Inc., "Extended Text" revealed "...Using the Braden Scale, patients who score 18 or less are at risk for breakdown... The most common sites for pressure ulcers include the sacrum, coccyx, ischial tuberosities... Factors such as chronic moisture from fecal and urinary incontinence, sheer, immobility, loss of sensory perception, level of activity, and poor nutrition can contribute to pressure ulcer formation. Inspection of the patient's skin and bony prominence's should occur at least daily. Devices,..., antiembolic stockings,... should be removed for the skin inspection... ASSESSMENT AND PREPARATION Assessment ...5. Perform the risk assessment upon the patient's entry into the health care setting. Repeat assessments on a regularly scheduled basis or when there is a significant change in the patient's condition..."

Review of Mosby Nursing Skills titled "Pressure Ulcer: Treatment", copyright 2006-2016 Elsevier Inc., "Clinical Skills" revealed "...Document repositioning every 2 hours and indicate the position. Braden Scale is completed on admission and daily..."

1. Open medical record review, on 05/17/2016 through 05/20/2016, of patient #7 revealed a 75 year old female admitted on 02/23/2016 at 1424 with a diagnosis of "Left Hip Fracture". Record review revealed an Integumentary (Skin) assessment documented on 02/23/2016 at 2114, "darkened dry feet, Integrity: scab to L (left) shin" with a Braden Score of "16". Further review of the record revealed the next available documentation of skin assessment was on 02/24/2016 at 2000 (22 hours and 46 minutes later) with documentation of "urinary incontinence, Skin: dry, use pillow B/t (between) knees/ankles, generalized weakness, LLE (left lower extremity) limited movement", Interventions: pillows, Turn q2 (every 2 hours), float heels off mattress" with Braden Score of 14. Further review of Skin Assessment revealed documentation on 02/25/2026 at 0750, "Skin: dry, Integrity: scab to L (left) shin, Skin Turgor: Non-tenting" with a Braden Score of 13. Review of Skin Assessment revealed documentation on 02/25/2016 at 2240 "Integrity: scab to L shin, crack between upper buttocks" with a Braden Score of 12. Further review of skin assessment revealed documentation on 02/26/2016 at 0930 "Integrity: crack between upper buttocks, Interventions: dsg (dressing) placed, protocol started." Review of Physician's Orders revealed an order dated 03/01/2016 at 1610 "Consult Wound Ostomy Continence, Silicone foam (Allevyn) 3x3 dressing, change every 5 days, Sensi-Care green #3 barrier cream (routine daily and prn (as needed) incontinence of urine or stool)." Review of Wound Care consult revealed documentation on 03/01/2016 at 1613 "Pressure Ulcer Location: Buttock Location Orientation: Left Staging: Unstageable Wound Description: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in wound bed. This is NOT a pressure ulcer; appearance consistent with moisture acquired skin damage and partial thickness skin loss. Present on Admission: No."

Review of Nursing Flowsheets documented by a Registered Nurse and Nurse Tech (certified nursing assistant) from 02/23/2016 at 2114 through 02/26/2016 at 0659 revealed no available documentation of patient #7 being turned every 2 hours as ordered based on Braden Score. Further review of nursing flowsheets documentation on 02/27/2016 at 0546 revealed patient was turned to right side. Further review revealed documentation on 02/27/2016 at 1338 of patient lying on right side. Further review revealed no available documentation of patient #7 being turned from 02/27/2016 at 0546 until 02/27/2016 at 1338 (7 hours and 52 minutes later).

Interview with nursing staff during tour on 05/17/2016 at 1055 revealed skin assessments should be completed on every shift. Braden Scales should be completed at least every 24 hours. If a patient's total Braden Score is less than 18, we should turn patient every 2 hours unless patient is able to turn themselves. Nurses document skin assessment and patient turning on their daily shift assessment. We are only required to contact Wound Care Nurse if wound is Stage III or Stage IV. We should lift up the corner of the foam dressing to visualize the decubitus. Interview confirmed there was no evidence of a decubitus documented prior to 02/25/2016 (2 days after named patient's admission).

Based on policy and procedure review, medical record review and staff interview, facility staff failed to document every two hour turning and repositioning for 3 of 4 patients with a Braden Score less than or equal to 18 (#9, #7, and #11).

Findings include:

Review of the hospital's "Policies and Procedures" titled "Nursing Process and Physical Assessment Standards", date approved 10/09/2015, revealed ". . . Nursing Process Standards for All Inpatients . . . Implementation Interventions documented as soon as possible after the time of completion. . . ."

Review of the hospital's "Clinical Skills Pressure Ulcer: Risk Assessment and Prevention Extended Text", copyright 2006-2016 Elsevier Inc., revealed ". . . Using the Braden Scale (used to determine a patient's level of risk for development of pressure sores), patients who score 18 or less are at risk for breakdown. . . ."

Review of the hospital's Electronic Medical Record (EMR) "Braden Scale Interventions" revealed, "If Braden less than or equals 18 . . . Reposition every 2 hours . . ."

1. Closed medical record review, on 05/17/2016 through 05/20/2016, of Patient #9 revealed an 84 year old female who was admitted to the named facility on 10/12/2015 with acute encephalopathy (disease, damage, or malfunction of the brain) and urinary tract infection (UTI) per a physician's History and Physical (H&P), dated 10/12/2015 at 1908. According to a physician's Discharge Summary, dated 11/10/2015 at 0958, Patient #9 was discharged to a Skilled Nursing Facility (SNF) on 11/10/2015 with a discharge diagnosis of "Stroke: Non-dominant IVH (intraventricular hemorrhage; bleeding into the brain's ventricular system) secondary to coumadin (medication used to treat and prevent blood clots associated coagulopathy (a condition in which the blood's ability to clot is impaired) in setting of uncontrolled hypertension (high blood pressure). Review of Patient #9's electronic medical record (EMR) for her 10/12/2015-11/10/2015 hospitalization revealed a nursing admission assessment on 10/12/2015 at 2140 with a documented Braden Score of 17. Further review of Patient #9's EMR Nursing flowsheet that included patient position changes revealed missing documentation for every 2 hour repositioning on 10/16/2015 from 1100-2000 (9 hours); on 10/19/2015 from 0700-1000 (3 hours), and 1100-2000 (9 hours); on 10/22/2015 from 1300-1600 (3 hours); on 10/23/2015 from 0100-0400 (3 hours); on 10/28/2016 1500 to 10/29/2016 at 0800 (18 hours), and 10/29/2016 1800 to 10/31/2016 2050 (51 hours, 50 minutes); on 10/31/2016 2050 to 11/01/2015 2047 (23 hours, 3 minutes); on 11/01/2015 2047 to 11/02/2015 0000 (3 hours, 13 minutes); on 11/02/2015 0000 to 11/04/2015 2000 (68 hours); on 11/05/2015 0300-0815 (6 hours, 15 minutes) and 0815-2000 (11 hours, 45 minutes); on 11/05/2015 2000 to 11/06/2015 0815 (12 hours, 15 minutes); on 11/06/2015 0815 to 11/07/2015 0915 (25 hours); on 11/07/2015 0915 to 11/08/2015 0840 (23 hours, 25 minutes). 11/08/2015 at 0840 documentation revealed the patient was on her left side and was able to turn self. No other documentation was found regarding patient position or turning prior to Patient #9's discharge on 11/10/2015 at 1750 (57 hours, 10 minutes). Further review revealed a discharge skin assessment on 11/10/2015 at 0820 with a documented Braden Score of 12 for Patient #9.

Further review of Patient #9's closed record revealed a physician's H&P, dated 11/19/2015 at 0233, which indicated Patient #9 was readmitted to the named facility on 11/18/2015 with "Acute encephalopathy . . . confusion and aphasia (language disorder that affects a person's ability to communicate) with not following command. . . ." Record review revealed Patient #9 was discharged back to the SNF on 12/01/2015. Review of Patient #9's EMR for her 11/18/2015-12/01/2015 hospitalization revealed a nursing admission assessment on 11/19/2015 at 0113 with a documented Braden Score of 10. Further review of Patient #9's EMR Nursing flowsheet that included patient position changes revealed missing documentation for every 2 hour repositioning on 11/19/2015 0040-0905 (9 hours, 25 minutes); on 11/19/2015 1115 to 11/21/2015 1132 (48 hours, 17 minutes); on 11/21/2015 1132-2213 (10 hours, 41 minutes); on 11/21/2015 2213 to 11/22/2015 1154 (13 hours, 41 minutes); on 11/22/2015 2005 to 11/23/2015 0850 (12 hours, 45 minutes) and 0850-1700 (8 hours, 10 minutes); on 11/23/2015 1700 to 11/24/2015 1058 (17 hours, 58 minutes) and 1058-1400 (3 hours, 2 minutes); on 11/26/2015 1834 to 11/27/2015 0800 (11 hours, 26 minutes); on 11/27/2015 2000 to 11/29/2015 0830 (36 hours, 30 minutes); on 11/29/2015 1948 to 11/30/2015 0353 (8 hours, 5 minutes); on 11/30/2015 0604 to 12/01/2015 0944 (27 hours, 40 minutes) and 0944-1726 (7 hours, 42 minutes). Further review revealed a discharge skin assessment on 12/01/2015 at 1050 with a documented Braden Score of 13.

Further review of Patient #9's closed record revealed a physician's H&P, dated 01/05/2016 at 1214, that stated the patient was admitted on 01/04/2016 from the SNF with a diagnosis of UTI, mild renal insufficiency (a medical condition in which the kidneys fail to adequately filter waste products from the blood) . . ." The patient was discharged back to the SNF on 01/11/2016. Review of the Patient #9's 01/04/2016-01/11/2016 hospitalization revealed a nursing admission assessment on 01/05/2016 at 0144 with a documented Braden Score of 14. Review of Patient #9's EMR Nursing flowsheet that included patient position changes revealed missing documentation for every 2 hour repositioning on 01/05/2016 0138-0838 (7 hours) and 0838-2000 (11 hours, 22 minutes); on 01/05/2016 2000 to 01/06/2016 0830 (12 hours, 30 minutes); on 01/06/2016 1840 to 01/08/2016 1001 (15 hours, 21 minutes) and 1243-2114 (8 hours, 31 minutes); on 01/09/2016 0316-0824 (5 hours, 8 minutes) and 0824-2027 (12 hours, 3 minutes); on 01/09/2016 2027 to 01/10/2016 0826 (11 hours, 59 minutes); on 01/10/2016 0903 to 01/11/2016 0800 (22 hours, 57 minutes).

Interview, on 05/19/2016 at 1300, with a Nursing Technician (CNA #2) who provided care for Patient #9 during her 01/04/2016 admission revealed the night shift CNA will report to the day shift CNA when a patient was last turned. "Then I know when to turn." Turning is "not always exactly two hours. Maybe 10 to 15 minutes late. I will be in the room more than once in a hour. She (the named patient) was very incontinent. We did change her at least every two hours and turned her."

Telephone interview, on 05/20/2016 at 1045, with a Registered Nurse (RN #7) who took care of Patient #9 during her 11/18/2015 admission revealed the nurses and techs work together with patients that are incontinent or at risk for pressure ulcers. RN #7 stated they turn patients every two hours and keep them dry as much as possible. RN #7 reported, "Techs mostly chart turning. Nurses don't always chart. I will turn the patient and tell the techs." RN #7 said, "We strive to do ulcer prevention."

Interview, on 05/20/2016 at 1105, with a Nursing Director (ND #1) revealed a patient with a Braden Score less than 18 is at risk for skin breakdown. ND #1 reported she expects staff to reposition at risk patients. "Repositioning should be documented by nurses and technicians."
Telephone interview, on 05/20/2016 at 1200, with a night nurse (RN#8) who cared for Patient #9 during her 10/12/2015 admission revealed a patient who is incontinent or at risk for a pressure ulcer would be turned every two hours and kept clean and dry. RN #8 reported he was new in October and trying to learn his job. "I thought techs were charting turning and peri care." RN #8 stated, "I'm sure she was turned and cleaned."

2. Open medical record review, on 05/17/2016 through 05/20/2016, of Patient #7 revealed a 75 year old female admitted on 02/23/2016 at 1424 with a diagnosis of "Left Hip Fracture". Record review revealed an Integumentary (Skin) assessment documented on 02/23/2016 at 2114, "darkened dry feet, Integrity: scab to L (left) shin" with a Braden Score of "16". Review of Nursing Flowsheets documented by a Registered Nurse and Nurse Tech (certified nursing assistant) from 02/23/2016 at 2114 through 02/26/2016 at 0659 revealed no available documentation of Patient #7 being turned every 2 hours as ordered based on Braden Score. Further review of nursing flowsheets documentation on 02/27/2016 at 0546 revealed the patient was turned to right side. Further review revealed documentation on 02/27/2016 at 1338 of patient lying on right side. Further review revealed no available documentation of Patient #7 being turned from 02/27/2016 at 0546 until 02/27/2016 at 1338 (7 hours and 52 minutes later).

Interview with nursing staff during tour on 05/17/2016 at 1055 revealed skin assessments should be completed on every shift. Braden Scales should be completed at least every 24 hours. If a patient's total Braden Score is less than 18, we should turn patient every 2 hours unless patient is able to turn themselves. Nurses document skin assessment and patient turning on their daily shift assessment.

Interview, on 05/20/2016 at 1105, with a Nursing Director (ND #1) revealed a patient with a Braden Score less than 18 is at risk for skin breakdown. ND #1 reported she expects staff to reposition at risk patients. "Repositioning should be documented by nurses and technicians."

3. Open medical record review, on 05/17/2016 through 05/20/2016, of Patient #11 revealed a 64 year old male admitted to the named facility on 04/30/2016 with abdominal pain per a physician's H&P, dated 04/30/2016 at 2238. Review of the documented nursing assessment on 05/16/2016 at 0800 revealed Patient #11 had a Braden Score of 12. Review of Patient #11's EMR Nursing flowsheet that included patient position changes revealed missing documentation for every 2 hour repositioning on 05/16/2016 1002-2100 (10 hours, 58 minutes); on 05/16/2016 2100 to 05/17/2016 0054 (3 hours, 54 minutes) and 1000-2040 (10 hours, 40 minutes).

Interview, on 05/20/2016 at 1105, with a Nursing Director (ND #1) revealed a patient with a Braden Score less than 18 is at risk for skin breakdown. ND #1 reported she expects staff to reposition at risk patients. "Repositioning should be documented by nurses and technicians."

NC00115762, NC00115764, NC00116595