HospitalInspections.org

Based on record review and interview the hospital failed to ensure nursing care plans were updated to reflect the changing needs of the patient. In 1 of 10 medical records reviewed (#1) scheduled patient care was not documented or updated as needed. This deficiency has the potential to affect all 26 patients served by the facility at the time of survey.

Findings include:

Facility policy; "Hand-off Communication" reviewed 10/01/14 states; "Nurse to Aid Report must include: Summary of patient's overall status and expectations for shift: activity, mobility, nutrition, skin and incontinence care, isolation and reason, restraints, and any concerns for the shift."

Pt. #1, a quadriplegic and recent victim of a motor vehicle accident, required repositioning on a regular schedule. Upon admission on 06/15/2016 pt. #1 was scheduled to be repositioned every 2 hours according to the nursing care plan which included range of motion exercises.

Documentation of repositioning for the 24 hour period between 7:00 AM, 06/18/16 and 6:00 AM, 06/19/16 indicates pt. #1 was moved only 4 times out of a requisite 12 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/19/16 and 6:00 PM, 06/19/16 indicates pt. #1 was not moved or repositioned at all.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/20/16 and 6:00 PM, 06/20/16 indicates pt. #1 was moved or repositioned only 3 out of a requisite 6 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/21/16 and 6:00 PM, 06/21/16 indicates pt. #1 was not moved or repositioned at all.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/22/16 and 6:00 PM, 06/22/16 indicates pt. #1 was moved or repositioned only 3 out of a requisite 6 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/24/16 and 6:00 PM, 06/24/16 indicates pt. #1 was moved or repositioned only 3 out of a requisite 6 times.

Documentation of repositioning for the 24 hour period between 7:00 AM, 06/25/16 and 6:00 AM, 06/26/16 indicates pt. #1 was moved only 6 times out of a requisite 12 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/27/16 and 6:00 PM, 06/27/16 indicates staff attempted to move or reposition pt. #1 only 2 out of a requisite 6 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/28/16 and 6:00 PM, 06/28/16 indicates pt. #1 was moved or repositioned only 3 out of a requisite 6 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 06/30/16 and 6:00 PM, 06/30/16 indicates pt. #1 was moved or repositioned only 3 out of a requisite 6 times.

Documentation of repositioning for the 12 hour period between 7:00 AM, 07/02/16 and 6:00 PM, 07/02/16 indicates pt. #1 was moved or repositioned only 3 out of a requisite 6 times.

According to a wound progress note dated 07/04/16 (signed by the physician on 07/05/16) repositioning was increased to hourly. This was precipitated by the development of pressure ulcers on pt. #1's coccyx and sacrum.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/06/16 and 6:00 AM, 07/07/16 indicates pt. #1 was moved only 7 times out of a requisite 24 times and refusals were documented only twice.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/08/16 and 6:00 AM, 07/09/16 indicates pt. #1 was moved/repositioned only 9 times out of a requisite 24 times and refusals were documented only three times.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/09/16 and 6:00 AM, 07/10/16 indicates pt. #1 was repositioned only 9 times out of a requisite 24 times and refusals were documented only twice.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/10/16 and 6:00 AM, 07/11/16 indicates pt. #1 was moved or repositioned only 8 times out of a requisite 24 times and refusals were documented only once.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/12/16 and 6:00 AM, 07/13/16 indicates pt. #1 was moved only 14 times out of a requisite 24 times.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/13/16 and 6:00 AM, 07/14/16 indicates pt. #1 was moved only 13 times out of a requisite 24 times.

Documentation of repositioning for the 24 hour period between 7:00 AM, 07/14/16 and 6:00 AM, 07/15/16 indicates pt. #1 was moved only 14 times out of a requisite 24 times.

These findings were reviewed with Director of Quality A on 08/09/2016 at 3:30 PM. A stated that pt. #1's refusal of repositioning and declining skin condition should have been monitored and documented.