HospitalInspections.org

Based on record review and interview the hospital failed to have a well organized nursing service in that they nurses failed to carry out the physician's order to turn 1 of 1 (Patient #4) patients every 2 hours .

Findings included:

Patient #4 was admitted on 06/30/19 with multiple comorbid disorders. The Medical Record reflected patient repositioning as follows: on 06/30/19 at 1434 patient was positioned on the left side and repositioned at 2254 to the right side. On 07/01/19 at 0316 the patient was still documented as laying on the right side, at 0535 the patient was repositioned to his back and at 2230 he was repositioned to the left side. On 07/02/19 the documentation stated the patient was repositioned at 0100 and 0500, but no side was documented. There was no further documentation that the patient had been turned on that date. On 07/03/19 the record reflected the patient had been turned to the right side at 0552 and onto his back at 2300, there was no further documentation the patient had been turned on that date. On 07/04/19 the record reflected the patient was repositioned to his right side at 2000 and repositioned to his back at 2100, there was no further documentation the patient had be repositioned on this date. On 07/05/19 the patient was documented to be repositioned on his left at 0010 and his right side at 0400. The next documented reposition was at 1910. The patient was repositioned every 2 hours for the remainder of the day. On 07/06/19 from 0053 until 0511 the patient was documented as being repositioned every 2 hours. There was no documentation the patient had been repositioned until 2210 on that date. On 07/07/19 the first documentation the patient had been repositioned was at 0900 when the patient was placed in a chair. The patient was documented as being returned to the bed at 1100. There was no documentation the patient had been repositioned until 2030 on that date. The patient was repositioned every 2 hours until 0430 on 07/08/19. On 07/08/19 there was no documentation the patient had been repositioned from 0430 until 1845. The patient was documented as being repositioned to his back at 2030. The patient was documented as being repositioned at 2300, but there was no documentation of what side the patient was placed on. The next documented reposition was on 07/09/19 at 0320, there was no documentation of what side the patient was repositioned to. There was documentation that the patient had been repositioned every 2 hours until 0900. The next documentation that the patient had been repositioned was at 2003 when the patient was turned to the left side. At 2230 the wife refused for the patient to be turned. On 07/10/19 at 0003 the patient was repositioned to his right side where he remained until 0800. The patient remained on his right side from 1000 until 1400 when he was repositioned to his left side. The next documented reposition is not until 2045 where the patient was again documented to be on his left side. The documentation reflected the patient was turned every 2 hours until 07/11/19 at 0450, the next documented repositioning was at 2045. On 07/12/19 there was no documentation the patient had been repositioned from 0456 until 2045. On 07/13/19 there was no documentation the patient had been repositioned form 1400 until 2021. On 07/14/19 there was no documentation the patient had been repositioned from 0026 until 0602 and from 1500 until 2245. On 07/15/19 the only documentation the patient had been repositioned was at 1100, 1500 and 2045. On 07/16/19 there was no documentation the patient had been repositioned from 0236 until 1150. And from 1610 until 2043. There was no documentation the patient had repositioned from 2043 until 0413 on 07/17/19. On 07/17/19 there was no documentation the patient had been turned from 0413 until 1903. The patient had been repositioned every 2 hours for the remainder of the day. On 07/19/19 the documentation reflected the patient had been repositioned every 2 hours until 0301, there was no documentation the patient was repositioned again until 2037. From 07/19/19 at 2037 until 07/20/19 at 0850 there was no documentation the patient had been repositioned. On 07/20/19 from 0800 until 1219 the documentation reflected the patient was turned every 2 hours. There was no documentation the patient had been repositioned form 1219 until 1954. The patient was repositioned every 2 hours the rest of the day. On 07/21/19 the only documentation that the patient was repositioned was at 0520 and 2202. On 07/22/19 The record reflected the patient was turned at 0050, 0200, 0346, and 0424. The next documented reposition was at 2057. There was no documentation of patient repositioning on 07/23/19. On 07/24/19 there was documentation the patient was repositioned at 0000 and 0444. On 07/25/19 there was documentation the patient had been turned at 0200 and 0541. On 07/26/19 there was documentation the patient had been repositioned at 0519, 1100, and 2200. On 07/27/19 there was documentation the patient had been repositioned at 0215, 0425, 1200, 1830, 1845, 1945, and 2245. On 07/28/19 there was documentation the patient had been repositioned at 0245, 0445, 1300, 1840, 1930, 2040 and 2240. On 07/29/19 there was documentation the patient had been repositioned at 0040, 0240, 0440, 1945, and 2156. On 07/30/19 there was documentation the patient had been repositioned at 0103, 0600, and 2015. The only documentation the patient had been repositioned on 07/31/19 was at 2135.
During a chart review on 10/08/19 that ended at 1250 Personnel #2, Personnel #3 and Personnel #4 were unable to provide proof that the patient had been turned every 2 hours. An audit of the chart by the surveyor provided the above information. Personnel #2 stated the patient had been placed on a low air loss mattress on 07/01/19. Personnel #4 stated the patient was placed on a Dolphin bed on 08/06/19. The Dolphin bed eliminates the need to turn the patient every 2 hours.