HospitalInspections.org

Based on document review and interview the facility failed to ensure a patient's pain was assessed per policy, skin care intervention was performed and Braden scores were completed accurately for one (1) of ten (10) medical records (MRs) reviewed. (Patient # 10)


The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview the facility failed to ensure a patient's pain was assessed per policy, skin care intervention was performed and Braden scores were completed accurately for one (1) of ten (10) medical records (MRs) reviewed. (Patient # 10)

Findings include:

1. The hospital policy titled, Assessment of Patients, Policy/Procedure Number: PCS - A, indicated on page 4, section 1.2 - a patient should should be assessed every four (4) hours while on the Intermediate Care Unit (IMCU) and/or Intensive Care Unit (ICU). This policy was last revised in 03/2023.

2. The hospital policy titled, Pain Assessment and Management PC 01.02.07, Policy/Procedure Number: ADPC 16.1, indicated on page 5, Evaluation (Reassessment) section 1.0 - to use an appropriate standard pain scale for assessing pain. Reassess pain level within 60 minutes of an intervention. This includes medications given regularly scheduled. This policy was last revised on 04/13/2022.

3. The hospital policy titled, Pressure Injury Prevention, Assessment and Treatment, Policy/Procedure Number: PCS-P 1.0, indicated on page 1, Background section 4.0 - patients at a greater risk for pressure injury development include, but are not limited to, any patient with a Braden score of 18 or below. On page 3, Evidence Based Interventions specific to Risk Assessment under Mobility (1-4 Braden Scale). Ensure all medium and high risk patients are turned on a regular schedule every two (2) hours. This policy was last revised in 02/2023.

4. Patient # 10 MR review:
a. Skin assessment flowsheets dated 12/10/2024 through 12/31/2024, lacked documentation the patient was repositioned on the following dates/time: 12/22/2024 at 6:00 am, 8:00 pm; 12/23/2024 at 2:00 am, 6:00 am, 8:00 pm; 12/27/2024 at 2:00 am, 6:00 am; 12/28/2024 at 10:00 pm; 12/29/2024 at 6:00 pm; and 12/30/2024 at 2:00 am. Wound note dated 12/17/2024 at 10:20 am, indicated skin assessment completed with left gluteus stage 2 measuring 3.8 cm (centimeters) in length, 1.6 cm width, and 0.1 cm in depth.
b. The Braden daily flowsheet indicated the patient's score was documented as 14 (moderate risk) on 12/10/2024. Braden daily flowsheet indicated the patient's score was documented as 14 (moderate risk) on 12/22/2024 despite the fact the patient had developed a pressure ulcer. The Braden daily flowsheet indicated a patient score of 12 - 13 (high risk) until discharge to the rehabilitation unit on 12/31/2024.
c. Pain assessment flowsheet dated 12/26/2024 at 12:55 pm, indicated the patient rated his/her right leg pain an eight (8) out of ten (10). The patient was administered pain medication. The patient's pain was reassessed at 3:52 pm; at that time the patient indicated his/her right leg pain was an eight (8) out of ten (10). The patient was administered pain medication. The patient's pain was reassessed at 9:28 pm, and at that time indicated his/her pain was zero (0). The pain flowsheet lacked sixty (60) minute reassessments at 1:55 pm, 4:52 pm and the four (4) hour pain assessment which was due 7:52 pm.

5. In interview on 01/30/2025 at approximately 11:30 am with A # 2 (Systems & Regulatory Quality), confirmed patient # 10's pain was not assessed according to the policy. His/her pain should have been reassessed sixty (60) minutes after an intervention such as pain medication administration.

6. In interview on 01/30/2025 at approximately 12:45 pm with N # 1 (Registered Nurse-RN/Intermediate Care Unit Manager), confirmed pain should be assessed every four (4) hours, and pain reassessment should be performed sixty (60) minutes following an intervention such as medication administration. All interventions should be charted in the flowsheet.

7. In interview on 01/30/2025 at approximately 2:15 pm with A # 2, confirmed patient # 10's Braden Score was 12 - 13 (high risk) which would initiate (per protocol) turning the patient every two (2) hours.