HospitalInspections.org

Based on clinical record review, Basic Wound Prevention Education review and interview, it was determined a Registered Nurse failed to ensure 3 (#1, #7 and #8) of 10 (#1-#10) patients reviewed were turned every two hours according to protocol or physician's orders. The failed practice placed the patients at risk of acquiring a pressure ulcer. The failed practice had the potential to affect all patients at risk of acquiring pressure ulcers. The findings follow:

A. Review of the Basic Wound Prevention Education revealed, "4. How can I actively participate in the wound prevention program during my work day at Cornerstone Healthcare Group Hospital? F. Schedule regular and frequent turning and repositioning for bed- and chair-bound individuals. Turn patients on pressure reducing mattresses at least every two (2) to four (4) hours, or at least every two (2) hours if they are on a non-pressure reducing mattress."

B. Review Patient #1's Daily Nursing Assessment records from 06/11/15 to 07/14/15 revealed Patient #1 was on a "Specialty Bed/Air Mattress" from 06/12/15 to 07/14/15. Review of the Daily Nursing Assessment records from 06/11/15 to 07/14/15 and Non-Behavioral Restraint Flow Sheets from 06/16/15 to 06/27/15 revealed there was no evidence the patient was turned every two hours on 06/15/15, 06/16/15, 06/27/15, 06/28/15, 06/30/15, 07/02/15, 07/03/15, 07/05/15 and 07/06/15. There was no evidence as to why the patient was not turned every two hours. The findings of A and B were confirmed in an interview with the Patient Care Manager on 07/16/15 at 0950.

C. Review of Patient #7's clinical record revealed a physician's order dated 06/24/15 at 1510 as "Must stay off coccyx. Scheduled Q2* (every two hours) side to side turns. Float heels off mattress." Review of the Daily Nursing Assessment records from 06/24/15 to 07/14/15 revealed there was no evidence Patient #7 was turned every two hours on 06/28/15, 06/29/15, 06/30/15, 07/02/15 to 07/05/15, 07/08/15 and 07/10/15 to 07/12/15. There was no evidence as to why the patient was not turned every two hours. The findings were confirmed in an interview with the Patient Care Manager on 07/15/15 at 1335.

D. Review of Patient #8's clinical record revealed a physician's order dated 07/03/15 at 1500 as "Turns Q2* around the clock-no exceptions". Review of the Daily Nursing Assessment records from 07/03/15 to 07/14/15 revealed there was no evidence Patient #7 was turned every two hours on 07/03/15 to 07/07/15, 07/09/15 and 07/11/15. There was no evidence as to why the patient was not turned every two hours. The findings were confirmed in an interview with the Patient Care Manager on 07/15/15 at 1410.