HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 5 clinical records (Pt #1) reviewed for pressure ulcer prevention and nursing care, the Hospital failed to ensure that nursing care was evaluated by failing to ensure Pt #1 was turned and repositioned every 2 hours, as required.

Findings include:

1. On 4/11/2023, the Hospital's Clinical Guidelines for Pressure Injury (release date 06/2022) was reviewed and indicated " ...Standard interventions for all patients can include but are not limited to...repositioning orders (minimum every 2 hour)..."

2. -Pt #1's clinical record, dated 1/3/2023 through 2/22/2023, was reviewed and indicated:
-Pt #1's history & physical (dated 1/3/2023) noted Pt #1 was admitted on 1/3/2023 with the following diagnoses: "End stage renal disease, chronic respiratory failure, chronic hypotension, chronic anemia, severe protein calorie malnutrition, sickle cell disease ..."

-Pt #1's admission Braden [risk of developing a pressure ulcer] assessment, dated 1/4/2023 indicated, " ...Braden scale -13 - moderate risk ..."

-Pt #1's wound assessment note, dated 1/4/2023, indicated, "Pressure injury (Sacrum) - Wound onset type (present on admission) - unstageable - Wound length (3 cm), wound width (2.5 cm), wound depth (unable to determine)"

-Pt #1's repositioning notes (dated 1/3/2023 through 2/21/2023) were reviewed and indicated that every 2 hour turns were not completed on the following dates/times:
-1/12/2023 - to right side at 12:00 AM and to prone position at 6:00 AM (6 hours later)
-1/15/2023 - to right side at 2:00 PM and to supine position at 6:00 PM (4 hours later)
-1/19/2023 - to supine position 6:00 PM and to left side at 10:10 PM (4 hours and 10 minutes later)
-1/20/2023 - to left side at 9:00 AM and to supine position at 2:48 PM (5 hours later and 48 minutes later)
-1/22/2023 - to supine position at 6:00 PM and to right side at 9:38 PM (3 hours and 38 minutes later)

3. On 4/11/2023 at 1:30 PM, an interview was conducted with the Wound Care Nurse (E #6). E #6 stated patients with pressure ulcers should be turned and repositioned every 2 hours.

4. On 4/11/2023 at 2:30 PM, an interview was conducted with the Attending Physician (MD #2). MD #2 stated that patients with pressure ulcers should be turned/repositioned every 2 hours.

B. Based on document review and interview, it was determined that for 1 of 5 clinical records (Pt #1) reviewed for weight monitoring, the Hospital failed to ensure that nursing care was evaluated by failing to ensure that Pt #1 was weighed weekly, as ordered.

Findings include:

1. On 4/12/2023, the Hospital's policy titled, "Weight Measurement" was reviewed and indicated, "...Weight is an anthropometric measurement used in conjunction with other information to calculate estimated energy, protein, and fluid needs...Weight change over time is an important indicator of nutritional status and fluid status...The policy of the hospital is to ensure proper measurement of patient weights..."

2. On 4/12/2023, Pt #1's clinical record, dated 1/3/2023 thru 2/22/2023, was reviewed and indicated:
-The Physician's order, dated 1/3/2023, required, "Pt #1 is to be weighed weekly on Wednesday."
-Pt #1's weights were documented as the following:
-admission 1/3/2023 - 192.4 lbs
-1/11/2023 - 201 lbs
-1/18/2023 - 200 lbs
-1/26/2023 - 200 lbs
-2/1/2023 - 194 lbs
-2/8/2023 - 186.5 lbs
-2/15/2023 - missing weight
-Nutrition notes (E #5 - Dietician) dated 2/13/2023 indicated, "...Nutrition interventions - to add Juven (nutrition supplement to support wound healing) twice a day and Prosource (protein supplement) three times a day to better meet needs...Monitor weight trends..."


3. On 4/11/2023 at 2:00 PM, an interview was conducted with the Dietician (E #5). E #5 stated that if the physician's order is for weekly weights, Pt #1 should have been weighed weekly. E #5 stated that she was not sure what happened. E #5 stated that Pt #1 should have been weighed weekly.

C. Based on document review and interview, it was determined that for 1 of 5 clinical records (Pt #1) reviewed for bathing, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to ensure that Pt #1 was bathed daily, per Hospital protocol.

Findings include:

1. On 4/12/2023, the Hospital's policy titled, "Routine Bathing" (dated 6/2022) was reviewed and indicated, "This policy establishes guidelines for routine patient bathing. Bathing cleans a patient's skin, stimulates circulation, provides mild exercise, and promotes comfort...Pre-moistened disposable cloths that contain a no-rinse surfactant are used for daily bathing..."

2. On 4/12/2023, Pt #1's bathing documentation (dated 1/3/2023 thru 2/22/2023) was reviewed and included the following:
-Pt #1 was not documented as bathed 19 of the 44 days in the hospital. Pt #1 was not documented as bathed on the following days: 1/9/2023, 1/14/2023, 1/16/2023, 1/17/2023, 1/19/2023, 1/20/2023, 1/21/2023, 1/22/2023, 1/25/2023, 1/27/2023, 1/28/2023, 1/29/2023, 1/30/2023, 1/31/2023, 2/5/2023, 2/13/2023, 2/17/2023 and 2/18/2023.

3. On 4/12/2023 at 11:29 AM, an interview was conducted with the Director of Clinical Services (E #8). E #8 stated that it is the policy and the expectation that each patient is bathed daily. E #8 stated that she is not sure the reason why Pt #1 was not bathed. E #8 stated that Pt #1 may not have been bathed due to his unstable condition.