HospitalInspections.org

Based on document review and interview, nursing services failed to document patient turn/repositioning or document how the patient was positioned to prevent pressure injury in 1 out of 10 patient (Patient 4) medical records reviewed.

Findings include:

1. Facility policy titled Protocol for Adult Skin and Wound Care, last publication date 06/24/2024, indicated under IV. PROTOCOL STATEMENTS, c. The protocol provides interventions to prevent or manage common clinical problems such as moisture associated skin damage, pressure injuries, and chronic wounds. Under HAPI - Skin Wound Algorithm, Is the patient at high risk for pressure injuries? Risk factors; Braden score greater than or less than 18 or sub scale greater than or less than 2, Yes, under Repositioning/Mobility: Turn/repositioning/reposition frequently according to patient condition. Under HAPI Skin Wound Treatment Algorithm under Unstageable, Relieve all pressure to area.

2. Review of Patient 4's medical record indicated the following:
a. The patient was admitted on 01/11/2024 and the medical record indicated the patient did not have a pressure injury or wound present upon admission.
b. On 01/11/2025, the Braden score was 9; the medical record lacked documentation of patient turn/repositioning/repositioning at 7:02 p.m.
c. On 01/13/2025, the Braden score was 14; the medical record indicated in the patient's turn/repositioning flowsheet that the patient required complete assistance but lacked documentation of how the patient was repositioned to prevent pressure injuries at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. The Pressure Injury Assessment flowsheet indicated at 4:00 p.m. the patient had a deep tissue pressure injury. The wound note per physical therapy indicated the patient had a deep tissue pressure ulcer to the right buttock/coccyx.
d. On 01/15/2025, the Braden score was 14; the medical record lacked documentation of patient turn/repositioning/repositioning at 6:00 a.m.
e. On 01/16/2025, the Braden score was 13; the medical record indicated in the patient turn/repositioning flowsheet that the patient required complete assistance but lacked documentation of how the patient was repositioned to prevent pressure injuries at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m.
f. On 01/19/2025, the Braden score was 17; the patient's turn/repositioning flowsheet indicated the patient was turn/repositioning at 9:00 a.m., next turn/repositioning was documented at 11:52 a.m., 52 minutes late and medical record lacked documentation of patient turn/repositioning/repositioning at 7:00 p.m.
g. On 01/20/2025, the Braden score was 17; the medical record lacked documentation of patient turn/repositioning at 11:00 a.m., 1:00 p.m., 3:00 p.m., and 5:00 p.m., and 7:00 p.m.
h. On 01/22/2025, the Braden score was 14 for the day shift; the medical record lacked documentation of patient turn/repositioning at 8:00 a.m., 1:00 p.m., 3:00 p.m. The Braden score for the night shift was 17; the medical record lacked documentation of patient turn/repositioning at 8:00 p.m., and 10:00 p.m.
i. On 01/23/2026 The Braden score was 17 from the night shift; the medical record lacked documentation of patient turn/repositioning at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m. The Braden score for the day shift was 14; the medical record lacked documentation of patient turn/repositioning at 8:00 a.m., 10:00 a.m. The medical record indicated the patient's position was not changed, and patient remained on their back at 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m.
j. On 01/24/2025, the Braden score was 16 for day shift; the medical record indicated the patient's position was not changed, and patient remained on their back at 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m. The Braden score was 17 for night shift; the medical record lacked documentation of patient turn/repositioning at 7:00 p.m. and indicated the patient's position was not changed, and patient remained on their back at 8:00 p.m., and 10:00 p.m.
k. On 01/25/2025, the Braden sore was 17 for night shift; the medical record indicated the patient's position was not changed, and patient remained on their back at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. The Braden score was 16; the medical record lacked documentation of patient turn/repositioning at 10:00 a.m.,12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m.
l. On 01/26/2025, the Braden score was 14 for day and night shift; the medical record lacked documentation of patient turn/repositioning at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m.
m. On 01/27/2025 the Braden score was 14 for night shift; the medical record lacked documentation of patient turn/repositioning at 12:00 a.m., 2:00 a.m., and 5:00 a.m. The Braden Score was 17 for day shift; the medical record indicated the patient's position was not changed, and patient remained on their back at 7:00 a.m., 9:00 a.m. and lacked documentation of patient turn/repositioning at 11:00 a.m.


3. Interview with A6 (Clinical Nurse Specialist) on 02/04/2025 at 1:15 p.m. indicated the following:
a. If the patient's Braden score is 18 or less, the patient is repositioned every two hours. Staff should document the position of the patient and how the patient was turn/repositioning. This documentation assists the staff on how the patient was previously repositioned, ensuring that the patient repositioned with each turn/repositioning to assist with prevention of pressure injury. Staff can document that the patient refused to reposition.
b. Confirmed the findings related to Patient 4, which included lack of documentation of turn/repositioning, documentation of the patient's reposition, and documentation that the patient's position was not changed, and patient had remained on their back.