HospitalInspections.org

NEW DEFICIENCY RESULTING FROM AN ON-SITE FOLLOW-UP 12/12/17.

Based on electronic clinical record review, nursing care plan review, Braden Scale review and policy and procedure review, it was determined there was a conflict with numeric value to assess for prevention pressure ulcer/skin breakdown in the policy, electronic clinical record, nursing care plan and Braden Scale. The failed practice did not assure patients would be accurately assessed for the risk of a pressure ulcer/skin breakdown to assist in the implementation of a plan of care. The failed practice had the likelihood to affect any patient at risk for a pressure ulcer/skin breakdown. Findings were:

A. Review of the policy and procedure titled, "Prevention of Pressure Ulcer/Skin Breakdown," received from the Assistant Director of Nursing at 11:20 AM on 12/12/17 showed that the following ranges for the risk of developing pressure ulcers to be: Low Risk 0-6; Moderate Risk 7-14; and High Risk 15 or >.
B. Review of the electronic clinical record scores received from the Chief Quality Officer at 1:10 PM on 12/12/17 showed that the ranges for the risk of developing pressure ulcers to be: Score > (greater than) or equal to 18, low risk; Score 14-17, moderate risk; and Score < (less than) 14, high risk.
C. Review of the nursing care plan Braden Scale received from the Chief Quality Officer at 1:10 PM on 12/12/17 showed that the ranges for implementation of nursing actions to prevent pressure ulcers to be: At Risk Braden 15-18; Moderate Risk Braden 12-14; High Risk Braden < 11; and Severe Risk Braden < 9.
D. Review of the Braden Scale itself received from the Chief Quality Officer at 1:10 PM on 12/12/17, showed the ranges for the risk of developing pressure ulcers to be: Mild Risk 15-18; Moderate Risk 13-14; High Risk 10-12; and Severe Risk 9 or <.
E. During an interview with the Chief Quality Officer and the Infection Control Nurse at 12:45 PM on 12/12/17, both verified the findings in A-D.