HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff repositioned one of 13 sampled patients (Patient 13) every two hours as per the physician's order. This failure created the risk of substandard health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Core: Clinical Guidelines for Pressure Injury dated June 2022 showed the following:

* The standard interventions for all patients can include a positioning order (minimum Q2 hour turns).

* The Documentation section showed to document the execution of order within the electronic medical record.

On 9/6/24 at 1536 hours, an interview and concurrent review of Patient 13's medical record was conducted with the Director of Quality Management and Director of Wound Care.

Patient 13's medical record showed Patient 13 admitted to the hospital on 6/24/24.

Review of the physician's order dated 6/24/24 at 2039 hours, showed to reposition the patient q2h.

Review of the reposition document showed the following:

* On 7/30/24 at 1844 hours, the patient's position was supine.
* On 7/30/24 at 2000 hours, the reposition was not done.
* On 7/31/24 at 1817 hours, the patient was repositioned to supine.
* On 7/31/24 at 2000 hours, the patient was repositioned to supine.
* On 8/7/24 at 0654 hours, the patient was repositioned to left side.
* On 8/7/24 at 0826 hours, the patient was repositioned to left side.
* On 8/7/24 at 1800 hours, the patient was repositioned to supine.
* On 8/7/24 at 2000 hours, the patient was repositioned to supine.
* On 8/8/24 at 0810 hours, the patient was repositioned to left side
* On 8/8/24 at 1000 hours to 1800 hours, the reposition was not done and the "execution remains on worklist, performed by other discipline."
* On 8/9/24 at 0010 hours, the patient was repositioned to left side.
* On 8/9/24 at 0212 hours, the patient was repositioned to left side.
* On 8/9/24 at 0626 hours, the patient was repositioned to left side.
* On 8/09/24 at 0823 hours, the patient was repositioned to left side.

During the concurrent interview, the Director of Quality Management stated there was no documented evidence for the patient's repositioning to be performed by other discipline in the medical record. The Director of Quality Management confirmed the above findings.