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SELECT SPECIALTY HOSPITAL - WEIRTON
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on document review, medical record review, and staff interviews, the facility failed to ensure that staff turned and repositioned two (2) of two (2) Patients (Patient #5 and #8) with physician orders to turn and reposition every two (2) hours. This failure has the potential to negatively impact all Patients receiving care at the facility. Cross Reference: 482.23(b)(6) Nursing Services: Adhere to the Policies and Procedures
Findings are as follows:
A review of the policy, titled "Inpatient Wound Program Policy and Procedure," dated 04/01/2023. The policy states, in pertinent part, "... Mobility deficit: ... Patients that are bed bound or with limited activity should be repositioned at least every two hours. Unless contraindicated by primary diagnosis, complications or co-morbidities, each Patient should be out of bed as determined by their mobility level ..."
A review of the medical records for Patient #5 was completed. The physician orders were reviewed and revealed an order for turning and repositioning every two (2) hours. The documented turning schedule was reviewed and revealed that on 02/29/2024 at 4:00 a.m.: "Repositioned: Lying right side;" and at 7:00 a.m., "Reposition: Lying left side." There was no documented evidence of repositioning between 4:00 and 7:00 a.m.
A review of the medical records for Patient #8 was completed. The physician orders were reviewed and revealed an order for turning and repositioning every two (2) hours. The documented turning schedule was reviewed, and revealed that on 03/28/2024 at 9:00 a.m., "Repositioned: Semi Fowler's Pillow support" and 2:00 p.m., "Repositioned: Sitting Up in chair." There was no documented evidence of repositioning between 9:00 a.m. and 2:00 p.m."
An interview was conducted with emp #3 on 04/03/2024 at 10:13 a.m. regarding Patient turning and repositioning. Emp #3 stated, "Everyone should be turning immobile Patients every two (2) hours" and confirmed that Patient #5 and Patient #8 were not turned according to physician order.