HospitalInspections.org

Based on policy review, medical record review, and interview, the registered nurse failed to ensure care was provided according to policy/procedure regarding turning/repositioning at risk patients for 1 of 4 patients (#5).

Findings included:

1. The facility policy "Skin Care Program (Prevention/Treatment of Pressure Ulcers)", last reviewed 04/13, indicated, "1. Patients assessed to be at high risk (a score of equal of less than 18 on the Braden Scale), will require utilization of the skin integrity care plan(s). ...6. Documentation of interventions will be individualized as per specific care plan. Refer to Patient Care Flowsheet and Progress Notes in this manual; or the computerized documentation." The computerized documentation indicated the following interventions in the skin integrity care plan for every two hours: turn/reposition, offer toileting, offer fluids, skin wet, head of bed elevated 30 degrees, and heels elevated.

2. The medical record (EMR) for patient #5 indicated an admission on 10/11/14 at 5:47 PM with an initial Braden Score from 1911 hours of 16 which triggered the implementation of the prevention measures. This assessment indicated the patient had very limited mobility and was bedfast. Subsequent Braden Scores were 18 at 0800 hours and 2000 hours on 10/12/14 and 19 at 0800 hours on 10/13/14 until discharge on 10/14/14. None of these assessments mentioned elevating the heels.

3. At 12:30 PM on 11/18/14, staff member #3, an RN (Registered Nurse) on the unit, indicated the nurse communicated to the PCTs (Patient Care Techs) when patients were on specific interventions, but it was the nurse's responsibility to ensure all of the care was provided. He/she indicated staff checked on the patients every hour and asked about any needs and repositioned as needed.

4. At 12:40 PM on 11/18/14, staff member #4, a PCT on the unit, indicated he/she used an assignment sheet, report from the nurses, and his/her familiarity with the patients to determine which patients required specific interventions. He/she indicated all staff checked on the patients hourly and assisted with any needs.

5. At 12:50 PM on 11/18/14, staff member #5, an RN on the unit, described the Skin Assessment policy and implementation of interventions to prevent any skin problems. He/she indicated two nurses performed the skin assessment on all patients coming to them from surgery and described conditions of concern, including redness, bruising, discoloration, and nonblanching skin which could indicate a deep tissue injury. He/she indicated the physician and wound care nurse would be notified of any concerns. He/she indicated all patients were checked on hourly and repositioned frequently, especially because of the types of patients on their unit.

6. At 1:30 PM on 11/18/14, staff member #1, the CNO, and #2, the Med/Surg Outcomes Specialist, confirmed the EMR lacked documentation the heels were elevated.