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BAYLOR SCOTT & WHITE PAVILION - TEMPLE 2401 S 31ST ST TEMPLE, TX 76508 Jan. 10, 2017
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on a review of documentation and interview, the facility failed to ensure that medical staff was accountable to the governing body for the quality of care provided to patients, as evidence by failing to ensure patients were turned every 2 hour per policy and physician orders.

Findings included:

Facility policy AH.1048.3.601.182 titled "Skin Care for Prevention and Treatment of Pressure Ulcers, Skin Tears, and Incontinence Skin Damage in the Adult Patient" states, in part:
I. "POLICY: Nursing staff are responsible for skin assessment, identification of potential or actual skin breakdown and management of skin care in the adult patient, in accordance with the following procedure. Nursing staff are responsible for appropriate documentation of assessment findings and interventions.
...
II. PROCEDURE(S):
A. Assessment:
1. Assess the skin condition of the patient within 8 hours of admission. Reassess every shift = 8 hours, or sooner with significant change in patient condition.
The RN is responsible for the initial admission assessment.
The LVN(sic) monitor as indicated.
Conduct a head to toe assessment of skin surfaces, particularly the heels, occiput, toes, sacrum, posterior buttocks, over bony prominences, thoracic spine(sic) scapula, ears, and between the knees.
2. Provide education to the patient and family/caregiver regarding pressure ulcer prevention, as appropriate.
3. Assess the patient's risk for developing pressure ulcers within 8 hours of admission, using the Braden Risk Assessment Scale. (See Attachment 1.) Reassess the patient's risk every shift, = 8 hours.
4. Record assessment findings and Braden Risk Scores in the inpatient record.
B. Prevention:
1. Initiate prevention measures (See Attachment 2, Pressure Ulcer Prevention Measures.) as indicated for the patient with any of the following:
Braden Risk Assessment Score of 18 or less
Pressure ulcer
Skin tear
Lower extremity ulcer
Incontinence
2. Select the appropriate support surface for the patient. (See Attachment 3a. Support Surfaces.)
3. Provide education to the patient and family/caregiver regarding pressure ulcer prevention measures, as appropriate."

Attachment 2, "Pressure Ulcer Prevention Measure" stated in part,
"Reduce Pressure.
* Reposition the patient every two hours when in bed."

A review of physician orders for Patient #1 revealed the following turning/repositioning orders:
* 5-25-16 at 8:30 pm "Turn patient every 2 hours" (discontinued 7-1-16 at 4:15 pm)
* 5-27-16 at 5:59 pm "Turn patient every 2 hours" (discontinued 6-26-16 at 7:01 pm)
* 6-29-16 at 5:01 pm "Turn patient every 2 hours" (discontinued 7-20-16 at 1:25 pm)

Review of the nursing documentation revealed that Patient was re-positioned and turned every 2 hours per physician order and policy with the exception of the following lapses:
On 05/26/16 the patient was turned at 1300 and not turned again until 2139 (with over 8 hours between).
On 05/27/16 the patient was turned at 2136 and not turned again until 0128 (with over 3 hours between).
On 05/29/16 the patient was turned at 0423 and not turned again until 0829 (with over 4 hours between).
On 05/30/16 the patient was turned at 1646 and not turned again until 2100 (with over 4 hours between).
On 05/31/16 the patient was turned at 2210 and not turned again until 0219 (with over 4 hours between).
On 06/02/16 the patient was turned at 0158 and not turned again until 0601 (with over 4 hours between).
On 06/03/16 the patient was turned at 0030 and not turned again until 0742 (with over 7 hours between).
On 06/04/16 the patient was turned at 1400 and not turned again until 2000 (with over 6 hours between).
On 06/07/16 the patient was turned at 1700 and not turned again until 2100 (with 4 hours between).
On 06/08/16 the patient was turned at 1500 and not turned again until 2000 (with 5 hours between).
On 06/13/16 the patient was turned at 1400 and not turned again until 1800 (with 4 hours between).
On 06/14/16 the patient was turned at 0200 and not turned again until 0800 (with over 6 hours between).
On 07/03/16 the patient was turned at 2356 and not turned again until 0721 (with over 7 hours between).
On 07/05/16 the patient was turned at 0913 and not turned again until 1224 (with over 3 hours between).
On 07/06/16 the patient was turned at 0858 and not turned again until 1538 (with over 6 hours between).
On 07/09/16 the patient was turned at 0100 and not turned again until 0900 on 07/10/16 (with over 32 hours between).
On 07/18/16 the patient was turned at 1153 and not turned again until 1600 (with over 4 hours between).

In an interview on 01/10/17, staff member #2 confirmed that Patient #1 was not turned every 2 hours per physican order and facility based policy.