HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure one of one (#10) patient with an order to turn every two hours was turned. Failure to turn Patient #10 every two hours created the likelihood for skin breakdown. The failed practice had the likelihood to affect any patient at risk of skin breakdown. Findings follow.

A. Review of Physician orders showed an order to turn the patient every two hours starting on 05/30/19 at 4:21 PM.
B. Review of Flowsheets showed Patient #10 was not turned and repositioned every two hours at the following times:
1) 06/01/19 - from midnight until 4:00 AM and from 3:00 PM until 6:00 PM
2) 06/02/19 - from 2:00 PM until 7:30 PM
3) 06/05/19 - from 11:45 AM until 7:00 PM
4) 06/06/19 - from 9:00 AM until 1:00 PM, and from 1:00 PM until 7:00 PM
5) 06/07/19 - from 5:09 AM until 9:00 AM
6) 06/08/19 - from 5:00 AM until 8:00 AM , and from 3:30 PM until 7:30 PM
7) 06/09/19 - from 3:00 PM until 8:00 PM
8) 06/10/19 - from 4:00 AM until 7:00 AM
C. During an interview on 02/06/20 at 9:20 AM, the Special Projects Manager confirmed the findings in A and B.