HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 4 of 7 MRs reviewed for patients at risk of pressure ulcer development (Patient #'s 1, 2, 3, 4), nursing staff did not consistently document turning and repositioning and elevation of heels.

Findings include:

-- The hospital's policy and procedure (P&P) titled "Skin Care Policy and Procedure," dated 7/2015, described the following procedures: Nursing staff assess a patients risk for pressure ulcer development using the Braden Scale score (Braden Scale) which requires scoring of patients risk factors. For patients at risk for pressure ulcer development (i.e., Braden score <18) nursing staff implement skin care guidelines that correspond to the Braden subscale scores. The frequency of turning and positioning of patient in bed is based on the following subscores. For subscores of 1, 2, or 3 in the Braden subscale areas of sensory perception, activity and mobility, or scores of 1 or 2 for friction and shear, nursing staff should reposition the patient every 2 hours or more frequently if there is evidence of pressure on their skin. Heels should be elevated with pillows, heel protectors or floats. Repositioning should be documented in the MR.

-- Per review of Patient #'s 1, 2, 3 and 4 MRs, although nursing staff assessed the patients as being at risk for pressure ulcer development, documentation of turning and repositioning and heel elevation while in bed was incomplete.

Examples include:

-- Review of Patient #1 MR revealed that he/she was admitted on 11/5/15. From 11/12/15 to 11/13/15, nursing staff assessed the patient's Braden Scale score as 15 (mild risk) with friction and shear subscore of 2 (potential problem), mobility subscore of 2 (very limited), activity subscore of 3 (walks occasionally) and sensory perception subscore of 3 (slightly limited).

From 1:00 pm on 11/12/15 to 9:30 am on 11/13/15 (20.5 hours), nursing staff documented that the patient was in the supine position, head of bed elevated and "independent" with turning and repositioning.

There was no documentation in the MR indicating that nursing staff repositioned the patient during that time. Also, during that time period there was no nursing documentation indicating that Patient #1's heels were elevated.

-- Review of Patient #2's MR revealed he/she was admitted on 1/22/16.

On 1/22/16 at 5:00 pm, Patient #2's Braden Scale score was 16 with activity subscore of 1 (bedfast). From 7:00 pm on 1/22/16 to 6:00 am on 1/23/16, nursing staff documented that the patient was "independent" with turning and positioning. There was no documentation indicating the patient's position while in bed or that nursing staff ensured the patient was repositioned. Also, there was no documentation indicating that Patient #2's heels were elevated during that time.

-- Review of Patient #3's MR revealed he/she was admitted on 1/25/16. From 1/25/16 to 1/26/16, nursing staff assessed the patient's Braden Scale score as 16 (mild risk) with friction and shear subscore of 2 (potential problem) and mobility subscore of 2 (very limited).

On 1/26/16 from 7:00 am to 6:00 pm, nursing staff documented that the patient was in the supine position, head of bed elevated. From 6:00 pm on 1/26/16 to 12:00 am on 1/27/16, there was no documentation by nursing staff indicating what position Patient #3 was in or that Patient #3 was turned and repositioned. Also, with the exception of 1/25/16 at 9:00 pm, there was no nursing documentation indicating that Patient #3's heels were elevated during these times.

-- Review of Patient #4's MR revealed he was admitted on 1/19/16. At that time nursing staff documented that Patient #4 had a Stage 1 pressure ulcer located on his buttocks, described as redness, no Braden Scale score was documented.

On 1/20/16 nursing documentation indicated Patient #4's Braden Scale score as 17 (mild risk) with activity subscore of 1 (bedfast), mobility subscore of 3 (slightly limited) and friction and shear subscore of 2 (potential problem). Patient #4 was placed on his/her right side at 9:00 pm on 1/19/16 until 5:00 am on 1/20/16 (8 hours) with no change in position.

On 1/23/16 at 8:33 pm, Patient #4's Braden Scale score was 12 (high risk) with an activity subscore of 1 (bedfast), mobility subscore of 2 (very limited), and a friction and shear subscore of 1 (problem). Nursing documentation indicated Patient #4 was placed in the supine position from 4:00 pm on 1/23/16 to 11:00 pm on 1/23/16 (7 hours) with no change in position.

-- During interview with the Staff A on 1/28/16 at 1:00 pm, he/she acknowledged the finding of lack of nursing documentation indicating turning and repositioning for patients assessed as being at risk for skin break down in the MR.

Based on findings from document review, medical record (MR) review, and interview, in 1 of 7 MR's reviewed for provider orders, Patient #5's physician orders for medication administration were incomplete and unclear. The lack of clear and concise medication orders has the potential to lead to medication errors.


Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Medication Management Policy," dated 5/2012, indicated prescriber orders should include the patient's name, date of birth, name of medication, dose, route, frequency and/or administration time and reason for administering prn (as needed) medications. Also, "if a patient has a current active order for a medication, and a new order is written for the same or similar medication, the prescriber must specify in the new order the status of the previously prescribed order. For those orders which do not address the previous order, the Pharmacist will contact the prescriber for clarification."

-- However, review of Patient #5's MR revealed the following:

On 1/23/16 at 7:22 pm, Staff B ordered via CPOE (Computer Physician Order Entry) acetaminophen-Hydrocodone (217 mg-5 mg/10 ml) 12 ml oral every 4 hours prn (as needed) for moderate to severe pain. Also at 7:26 pm, Staff B ordered via CPOE Morphine injectable 3 mg intravenously (IV) every 4 hours prn severe pain.

On 1/24/16 at 9:20 am, Staff B wrote an order that stated "pain medication (either) every 4 hours while awake."

On 1/26/16 at 8:50 am, Staff B ordered "narcotic pain medication every 8 hours (either Lortab or Morphine)" and "Tylenol 325 mg capsule or liquid 4 hours after #2 while awake."

-- During interview on 1/27/16 at 1:00 pm with Staff C, he/she acknowledged the above orders were unclear and incomplete.

-- During interview on 1/28/16 at 1:30 pm with Staff D, he/she indicated the physician should have been called to clarify the orders.