HospitalInspections.org

Based on the interview and record review, the hospital failed to ensure that the licensed nurses who provided services in the hospital adhered to the policies and procedures of the hospital.

Findings included:

Patient #1 admitted on August 31, 2021, with a past medical history significant for hypertension, congestive heart failure, obstructive sleep apnea, and morbid obesity with multiple wounds. Patient #1 was seen by Personnel # 4 for wound care on 09/01/2021 and by Personnel #5 for admission to the facility.
Upon medical review, there was no Braden scale completed by Personnel # 5 upon admission and by Personnel # 1 .
Upon medical review, Patient #1 was not repositioned by the facility's staff as per the standard intervention, the documentation revealed patient is not turned and repositioned a minimum of every 2 hours.


During an interview on 01/04/2023 at 1200 PM. Personnel #1 and Personnel #2 were informed of the above findings. Personnel #1 and Personnel #2 confirmed the above findings.
Policy and Procedure:
According to hospital policy: CORE: Skin and Wound Care Program Overview Original Date: 2/2012 Purpose...Policy...1. Pressure Ulcer Risk Assessment a. Braden scale completed by admitting nurse upon admission...b. The wound care RN will perform the Braden Scale upon admission...

According to hospital policy: Core: Clinical guidelines for Non-pressure related wounds Original Date: 08/2012...Purpose...This policy and procedure establish the RN's role...Policy...4. Standard interventions for all patients can include but are not limited to:...e. Repositioning (minimum Q2 hour turns)...ii. Consider turning the schedule of Q1 hours..., multiple wounds