HospitalInspections.org

Based on interview and record review, the facility failed to follow pressure injury policy for 1 (P-1) of 8 records reviewed for patients with wounds, resulting in the evolution of a pre-existing wound and the development of an ear abrasion. Findings include:

P-1 is a 48-year-old male with a past medical history of diabetes and neuroendocrine tumors (on the liver, pancreas, and kidney), who was admitted to the facility on 7/16/25 after a 23-day acute hospital stay where he was treated for encephalopathy, bacterial meningitis, obstructive hydrocephalus post external ventricular drain, multifocal ischemic strokes involving bilateral cerebral and cerebellar hemispheres, and ventilator dependent respiratory failure. P-1 arrived at the facility with a tracheostomy and a feeding tube. Wounds present on admission were documented on the coccyx, groin/perineum, right heel, and back of head.

During medical record review, P-1's repositioning documentation was reviewed with the chief nursing officer, Staff C, on 10/7/25 at 1035. Staff C stated staff can chart "repositioned" under hourly rounding as well as document the patient position (i.e., left, right, supine, in chair) under the repositioned field. The following documentation was noted:

7/23/25 at 0600 staff documented repositioned, up in chair. No additional repositioning documentation was noted until 1600 when staff documented "repositioned."
7/25/25 at 1600 staff documented repositioned. No additional repositioning documented until 7/26/25 at 0000.
7/26/25 at 2300 staff documented pillow support, semi fowlers. No additional repositioning documented until 7/27/25 at 0800.
8/3/25 at 2100 staff documented pillow support, semi fowlers. No additional repositioning documented until 8/4/25 at 0500.
8/7/25 at 1756 staff documented pillow support, semi fowlers. No additional repositioning documented until 8/4/25 at 0700 when staff documented sitting in chair.
8/8/25 at 2200 staff documented pillow support, semi fowlers. No additional repositioning documented until 8/9/25 at 0713.
8/10/25 at 0000 staff documented repositioned, semi fowlers. No additional repositioning documented until 8/10/25 at 0800.
8/15/25 at 1012 staff documented repositioned. No additional repositioning documented until 8/15/25 at 1920 when staff documented up in chair.
8/15/25 at 2000 staff documented pillows, semi fowlers. No additional repositioning is documented until 8/16/25 at 0700.
8/19/25 at 0600 staff documented repositioned. No additional repositioning is documented until 8/19/25 at 1900.
8/21/25 at 1400 staff documented repositioned. No additional repositioning documented until 8/21/25 at 2100.
9/2/25 at 1100 staff documented pillow support, semi fowlers. No additional repositioning documented until 9/2/25 at 2000.
9/2/25 at 2200 staff documented repositioned. No additional repositioning documented until 9/3/25 at 0700.
9/6/25 at 0400 staff documented repositioned. No additional repositioning documented until 9/6/25 at 1000.
9/6/25 at 2000 staff documented repositioned. No additional repositioning documented until 9/7/25 at 1900.

The facility failed to document patient repositioning at least every two hours as indicated in policy.

Policy WC I-1 Pressure Injury Prevention (Issued 4/1/23). States Patients that are bedbound or with limited activity should be repositioned at least every two hours.