HospitalInspections.org

Based upon reviews of 1 of 7 medical records (patient #3), Wound Care policy and procedures, and staff interviews, the hospital failed to ensure the nursing care of each patient was evaluated and documented as evidenced by failing to ensure the Registered Nurse(RN) evaluated and documented, (as ordered on the Treatment Administration Record), patient #3's pressure wound treatments and his turn every 2 hours schedule during his admission dates of 07/29/09 through 12/22/09. Findings:

Review of patient #3's medical record revealed, Registered Nurse (RN) S11 documented on a form titled "Initial Skin Impairment Assessment", dated 07/30/09, that patient #3 was admitted with Respiratory Failure, MRSA (Methicillin-Resistant Staphylococcus aureus) sputum, COPD (Chronic Obstructive Pulmonary Disease) and T4 (4th thoracic vertebra) lesion with paraplegia.

Review of a form titled "Braden Scale For Predicting Pressure Score Risk", dated 07/30/09, revealed Wound Care Registered Nurse S11 documented patient #3 had a total score of 14 on the Braden Scale (the Braden Scale is a commonly used assessment tool that quantifies the degree to which a person is at risk for development of a pressure ulcer, the risk is great with a score of less than 17). Photographs were made of the pressure ulcers and were in patient #3's medical record.

Review of the Treatment Administration Record (TAR) revealed orders, dated 07/30/09 to "Turn every 2 hours (left to right) or (side to side) Float heels". Continued review of the TAR revealed there failed to be documented evidence the nurse documented this intervention for the following dates and times: 08/07/09 7pm-7am shift; 08/08/09 no documentation; 08/30/09 7pm-7am shift; 09/06/09 7am-7pm shift; 09/10/09 7am-7pm shift; 09/15/09 7am-7pm shift; 09/16/09 7pm-7am shift; 09/18/09 through 09/20/09 the 7pm-7am shifts; 10/02/09 7pm-7am shift;10/03/09 7p-7a shift; 10/05/09 through 10/07/09 7p-7a lacked documentation; and 10/10/09 7p-7a shift.

Interview, on 06/29/10, 1:30pm, with Licensed Practical Nurse (LPN) S12 confirmed a specialty bed (sand bed) was provided for patient #3 on 10/15/09. There were orders to "turn every 2 hours and shift sand every 2 hours". (It was noted patient #3 had a different type of specialty bed prior to the change to the sand bed.) On 11/12/09 the sand bed was found to be mal-functioning, as it would not "fluidize" the sand. LPN S12 was questioned as to what "fluidize" meant and she replied, it means the air circulates through the sand to keep it from clumping together". A replacement sand bed was obtained the same day for patient #3. On 11/13/09 the sand bed was replaced again as it would not fluidize the sand.

Review of the TAR revealed orders to "turn every 2 hours and shift sand". Review of the documentation revealed there lacked documented evidence this was done on the following dates and shifts: 10/20/09 7p-7a shift; 10/29/09 through 11/01/09 the 7p-7a shift; 11/04 and 11/05/09 7a-7p shift; 11/06 and 11/07/09 no shift documented; 11/08/09 7a-7p shift; 11/23 and 11/25 on 7a-7p shift; 12/03 and 12/06/09 7p-7a shift; 12/14,12/15 and 12/18/09 7a-7p shift.

An interview, on 06/29/10, with Director of Nursing (DON) S2, confirmed there lacked documentation the RN had turned (and/or supervised the procedure) patient #3 and shifted the sand (beginning 10/15/09) every 2 hours per wound care instructions/physician orders.