HospitalInspections.org

Based on review of medical records and staff interview it was determined the Registered Nurse (RN) failed to turn patients every two (2) hours as ordered for one (1) of one (1) patients who required turning (Patient #1). This failure creates the potential for an adverse outcome for all patients who require assistance with turning.

Findings include:

1. Review of the medical record for Patient #1 revealed a 7/8/16 physician order to turn the patient every two (2) hours. Review of nursing documentation for 7/15/16 and 7/16/16 revealed the patient was in bed and was not turned every two (2) hours.

Flowsheets were reviewed with the Chief Nursing Officer at 11:34 a.m. on 8/30/16. She acknowledged there was no documentation that Patient #1 was turned for the ten (10) hours between 2:00 p.m. on 7/15/16 and 12:00 a.m. on 7/16/16. Also, there was no documentation the patient was turned for the six (6) hours between 12:00 a.m. and 6:00 a.m. on 7/16/16.