The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NEW HANOVER REGIONAL MEDICAL CENTER 2131 S 17TH ST BOX 9000 WILMINGTON, NC 28402 Sept. 3, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, patient and staff interviews, facility staff failed to turn and reposition every two hours per hospital policy for 5 of 5 patients at risk for pressure ulcer development (#3, #10, #12, #13 and #14).

Findings include:

Review of the hospital's policy and procedure titled "Pressure Ulcer Prevention", last review/revision date of 03/13, revealed "...MODERATE PRESSURE ULCER PREVENTION MEASURES--BRADEN SCORE (a tool for predicting pressure sore risk) 12-16...Keep skin clean and dry...Protect skin from moisture; use under pads not diapers...Turn patient every 2 hours if patient can not turn self...No diapers while in bed...If bed bound, reposition every two hours...".

1. Open medical record review on 09/02/2015 of Patient #10 revealed a [AGE] year old patient admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]" reveals "he is nonverbal due to prior CVA (stroke).. Sacral/pressure ulcers present upon admission- consult Wound RN.." Record review revealed the patient 's Braden score upon admission was 11 with a Stage II ulcer present to left coccyx area. Record review revealed the patient arrived on the nursing unit at 1539 on 08/30/2015 with patient turning with position documented every 2 hours until 2200. Record review revealed patient turning with position documentation resumed on 08/31/2015 at 1106 (13 hours 6 minutes later) and continued every 2 hours.

Interview with WOC NM (Nurse Manager) #3, on 09/02/2015 at 1107, revealed the first documented Braden score of 16 or less triggers an order set to pop up in the computer system for skin care protocol. "Per protocol, turn patient every two hours if they can't turn themselves."

Interview with NM #2, on 09/02/2015 at 1305, revealed NM #2 expects staff to turn patients with a low Braden score of 13 every two hours and to document their interventions.

2. Open medical record review on 09/02/2015 of Patient #12's "Hospitalist H&P (History and Physical)", dated 08/21/2015 2358, revealed a [AGE] year old female patient admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]&P included, "Wheelchair dependence, Multiple sclerosis DX (diagnosed ) 30 YEARS AGO...". WOC Nurse Consult Note, dated 08/17/2015 1502, reported, "...Activity: Bedfast, Mobility: Very limited...Friction and Shear: Potential Problem, Braden Scale Score: 13...WOC Recommendations: Turn side to side every 2 hours...".

Review of Patient #12's electronic Nursing Assessment Flowsheet, on 09/03/2015, revealed a Braden score of 15 documented on 08/21/2015 at 0206 and a Braden score of 14 documented on 09/02/2015 at 2120. No evidence was found that the patient was turned and repositioned on 09/02/2015 from 2300-0520 (6 hours, 20 minutes).

Interview with WOC NM (Nurse Manager) #3, on 09/02/2015 at 1107, revealed the first documented Braden score of 16 or less triggers an order set to pop up in the computer system for skin care protocol. "Per protocol, turn patient every two hours if they can't turn themselves."

Interview with NM #2, on 09/02/2015 at 1305, revealed NM #2 expects staff to turn patients with a low Braden score of 13 every two hours and to document their interventions.

3. Open medical record review on 09/02/2015 of Patient #13's "Hospitalist History and Physical", dated 08/25/2015 0139, revealed a [AGE] year old female patient admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. WOC Nurse Consult Note, dated 08/25/2015 0841, revealed, "...Activity: Bedfast, Mobility: Very limited...Friction and Shear: Problem, Braden Scale Score: 13...Pressure Ulcer Buttocks Right (Active), Pressure Ulcer Staging Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not hide the depth of tissue loss.)...WOC Assessment:...Patient with healed scar tissue around L (left) buttocks, coccyx (tailbone) and heels. Only open area on R (right) buttocks POA (present on admission) pressure ulcer stg (stage) III. C/o (complaining of) pain to buttocks...WOC Recommendations: Turn side to side every 2 hours...".

Review of Patient #13's electronic Nursing Assessment Flowsheet, on 09/03/2015, revealed a Braden score of 13 on the patient's admission assessment on 08/25/2015 at 0640. Further review of electronic documentation revealed no evidence the Patient #13 was turned and repositioned on 08/30/2015 from 1000-1600 (4 hours); on 09/01/2015 from 1200-2134 (9 hours, 34 minutes); and on 09/02/2015 from 0552-0944 (3 hours, 52 minutes). Patient #13's current Braden score, documented on 09/02/2015 at 2132, was 12.

Interview with Patient #13, on 09/02/2015 at 1455, revealed the patient cannot turn herself. Patient #13 stated, "Been on my right side since last night."

Interview with WOC NM (Nurse Manager) #3, on 09/02/2015 at 1107, revealed the first documented Braden score of 16 or less triggers an order set to pop up in the computer system for skin care protocol. "Per protocol, turn patient every two hours if they can't turn themselves."

Interview with NM #2, on 09/02/2015 at 1305, revealed NM #2 expects staff to turn patients with a low Braden score of 13 every two hours and to document their interventions.

4. Open medical record review on 09/02/2015 of Patient #14's "Admission" H&P, dated 08/17/2015 0102, revealed a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]] (brain disease that alters brain function or structure) and severe PTSD (post traumatic stress disorder). WOC Nurse Consult Note, dated 08/24/2015 1431, revealed "...Activity: Bedfast, Mobility: Completely immobile,...Friction and Shear: Problem, Braden Scale Score: 9...Pressure Ulcer Coccyx (Active), Pressure Ulcer Staging Unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.)...Pressure Ulcer Back lower (Active), Pressure Ulcer Staging Stage 1...WOC Recommendations: Turn side to side every 2 hours...".

Review of Patient #14's electronic Nursing Assessment Flowsheet, on 09/03/2015, revealed a Braden score of 10 documented on the patient's admission assessment dated [DATE] at 0534. No documentation was found indicating the patient was turned and repositioned on 08/29/2015 from 1023-1600 ( 5 hours, 37 minutes) and 1600-2000 (4 hours); on 08/30/2015 from 0200-0824 (6 hours, 24 minutes) and 1111-2016 (9 hours, 5 minutes) on 08/31/2015 from 0000-0836 (8 hours, 36 minutes); from 2115 on 08/31/2015 to 09/01/2015 at 1000 (12 hours, 45 minutes); and on 09/01/2015 from 1600-2054 (4 hours, 54 minutes). Patient #14's last documented Braden score was 11 on 09/02/2015 at 2149.

Interview with WOC NM (Nurse Manager) #3, on 09/02/2015 at 1107, revealed the first documented Braden score of 16 or less triggers an order set to pop up in the computer system for skin care protocol. "Per protocol, turn patient every two hours if they can't turn themselves."

Interview with NM #2, on 09/02/2015 at 1305, revealed NM #2 expects staff to turn patients with a low Braden score of 13 every two hours and to document their interventions.

5. Closed medical record review on 09/02/2015 of Patient #3's "History and Physical", dated 06/24/2015 1623, revealed an [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (paralysis of one side of the body). "Wound Ostomy (surgically created opening in the body for the discharge of body wastes) Continence (the ability to control urine and fecal discharge) (WOC) Nurse Consult Note", dated 06/25/2015 1403, revealed "...WOC nurse consulted regarding pre existing pressure ulcer to patient left heel...WOC Recommendations: Skin care precautions: Turn side to side every 2 hours...Off load heels...". "Physical Therapy Evaluation", dated 06/27/2015 1139, revealed "...Patient able to transition from Supine To and from Short sit_with Total assistance...mechanical lift or dependent transfer prior to admit...Pt (patient) nonambulatory (not able to walk) ...". WOC RN (Registered Nurse) Consult note, dated 06/30/2015 0839, revealed "reconsult received for heel and buttock wounds...P500 LAL mattress (low air loss specialty mattress that reduces pressure, friction, shear and moisture) ordered...". Further review of medical record revealed Patient #3 was placed on specialty bed on 06/30/2015.

Review of Patient #3's electronic Nursing Assessment Flowsheet on 09/02/2015, revealed documentation on 06/24/2015 at 1742 of an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough) left heel ulcer and a Braden score of 13 (moderate risk for developing a pressure ulcer) on admission. Further review of electronic documentation revealed no documentation that the patient was turned and repositioned on 06/25/2015 from 0852-1600 (7 hours, 8 minutes); on 06/26/2015 from 0400-1100 (7 hours), 1100-2208 (11 hours, 8 minutes); on 06/27/2015 from 0000-0814 (9 hours, 14 minutes), 1000-2114 (11 hours, 14 minutes); on 06/28/2015 from 0231-0800 (5 hours, 29 minutes) and 1400-2000 (6 hours). Review of the Assessment Flowsheet revealed documentation of a hospital acquired Stage 1 (intact skin with non-blanchable (does not lighten in color when pressed and released) redness of a localized area usually over a bony area) pressure ulcer on Patient #3's sacrum on 06/28/2015 at 0236.

Interview with WOC NM (Nurse Manager) #3, on 09/02/2015 at 1107, revealed the first documented Braden score of 16 or less triggers an order set to pop up in the computer system for skin care protocol. "Per protocol, turn patient every two hours if they can't turn themselves."

Interview with RN #1, on 09/02/2015 at 1250, revealed interventions for a patient with a Braden score of 13 - "Turn q (every) two hours, lift her heels, skin dry, no friction - especially when boosting up in bed. I would get orders for barrier cream." RN #1 reviewed her 06/27/2015 electronic documentation for Patient
#3 and stated, "I didn't chart that I turned her every two hours. That's just my poor documentation." RN #1 did not verbally indicate that she turned Patient #3 every two hours.

Interview with NM #2, on 09/02/2015 at 1305, revealed NM #2 expects staff to turn patients with a low Braden score of 13 every two hours and to document their interventions.

Interview with RN #4, on 09/02/2015 at 1310, revealed interventions for a patient with a Braden score of 13 would include, "Wound consult. Keep heels elevated. Keep her turned every two hours. Keep her dry." RN #4 stated, "I don't see where I charted anything. There's a big gap. I was in the room more than that. I know I gave meds." RN #4 did not verbally indicate that she turned Patient #3 every two hours.

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