HospitalInspections.org

Based on policy review, medical record review, and interviews with staff, the Acute Care Hospital (ACH)'s administrative staff failed to ensure hospital staff adhered to applicable nursing policies and procedures for 1 of 14 sampled patients (Patient #11) who presented to the hospital for inpatient services from 4/12/25 to 5/30/25.

This deficient practice resulted in a failure by staff to appropriately reposition Patient #11 (P11), a patient who presented to the ACH with stroke-like symptoms, in accordance with hospital policy and accepted standards of practice to prevent the development or worsening of pressure-related injuries.

Findings include:

1. Review of the 12/2023 policy "Basic Care Management - Adults - General Nursing" revealed in part:

a. "Purpose: To provide a guide for the basic care and management of all adult patients."

b. "Policy: Nursing care is provided according to nursing standards, policies, procedures, and protocols that are individualized to the patient."

c. "Intentional Rounding: Intentional Rounding is done hourly from [6:00 AM to 10:00 PM] and every 2 hours from [10:00 PM to 6:00 AM] to address the following: pain management; positioning; personal needs, especially toileting; personal environment; environmental safety."

2. Review of Patient #11 (P11)'s 4/12/25 medical record revealed the following:

a. On 4/12/25 at 3:52 PM, P11 presented to the ACH via ground ambulance with complaints of stroke-like symptoms, including left-sided weakness, slurred speech, and paresthesia (a sensation of tingling, "pins and needles," or numbness), and a history of hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol), hypothyroidism (abnormally low thyroid activity), prior pulmonary embolism (a blood clot or other blockage of an artery in the lungs), and a history of tobacco use.

b. Staff obtained an initial set of vital sign measurements, which revealed an elevated blood pressure (164/86 mmHg). The patient then underwent computed tomography (CT) imaging of the head, which revealed the presence of a middle cerebral artery (MCA) stroke. At 4:54 PM, staff administered Tenecteplase (TNK) (a medication used to dissolve blood clots) and placed the patient on tube feeding. At 9:00 PM, staff transferred the patient to the Critical Care Unit (CCU).

c. On 4/15/25 from 6:57 PM to 10:59 PM, staff failed to reposition the patient.

d. On 4/16/25 from 12:05 AM to 07:00 AM, staff failed to reposition the patient.

e. On 4/18/25, from 6:00 AM to 3:40 PM, staff failed to reposition the patient.

f. On 4/20/25 from 11:00 PM to 4/21/25 at 4:00 AM, staff failed to reposition the patient.

g. On 4/21/25 from 4:00 AM to 12:00 PM, staff failed to reposition the patient.

h. On 4/24/25 at 2:30 PM, staff discharged the patient.

3. During an interview on 6/5/25 at 1:15 PM, Staff N (Registered Nurse (RN)) reported hospital policy required staff to reposition patients at least once every two hours, or more frequently if indicated by the patient's Braden Scale (an assessment utilized to assess patients' risk of pressure ulcer development). Staff N reported staff would perform a Braden Scale assessment for each patient to identify risk factors for pressure sores and to inform preventive interventions (e.g., frequent repositioning), depending on the patient's mobility, nutrition, moisture, ability to feel pain, and activity level. Staff N reported nursing staff and Patient Care Technicians (PCTs) shared responsibility for repositioning patients in accordance with hospital policy, as well as documenting said repositioning.

4. During an interview on 6/5/25 at 11:30 AM, Staff M (PCT) reported hospital policy required staff to reposition patients at a minimum of once every two hours. Staff M acknowledged P11's medical record did not include evidence of bihourly repositioning, as required by hospital policy, during multiple periods of the hospitalization.

5. During an interview on 6/5/25 at 3:00 PM, Staff L (Interim Director) reported they expected staff to adhere to hospital policy requiring repositioning at a minimum of two hours, or more frequently if indicated by the patient's condition. Staff L acknowledged staff documented two variances (deviations from expected standards of patient care) related to staff failures to reposition the patient, per hospital policy. Staff L identified five time periods in which staff failed to reposition P11 for periods of approximately 4 to 9 hours, including the following: on
4/15/25 from 6:57 PM to 10:59 PM, on 4/16/25 from 12:05 AM to 07:00 AM, on 4/18/25 from 6:00 AM to 3:40 PM, on 4/20/25 from 11:00 PM to 4/21/25 at 4:00 AM, and on 4/21/25 from 4:00 AM to 12:00 PM.