HospitalInspections.org

Based on document review and interview, the facility failed to ensure complete documentation of repositioning taking place in 2 of 13 medical records reviewed (patient 2 and 4).

Findings Include:
1. Review of policy titled: Policy # H-PC 10-003, Release date 06/2016, "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds", indicated under documentation:
...Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime...,
...under Policy: Prevention Components...
...Repositioning at intervals determined per patient's risk level and conditions...
...High risk patients are turned a mininmum of every 2 hours...


2. Review of patient #2's medical record indicated a doctors order for repositioning every 2 hours on admission. The medical record also indicated a lack of repositioning every 2 hours in documentation on the "Daily Patient Rounding Log", on 3/11/2019 dayshift, 3/13/2019 dayshift, 3/14/2019 dayshift, 3/17/2019 nightshift, 3/21/2019 dayshift, 3/23/2019 dayshift, 3/29/2019 nightshift, 4/10/2019 nightshift and 4/15/2019 dayshift.

3. Review of patient #4's medical record indicated 4 shifts, 4/9/2019, 4/21/2019, 4/25/2019 and 4/26/2019, lacked repositioning documentation on the facility "Daily Patient Rounding Log".

4. On 5/28/2019 at 1:35pm, wound care coordinator (P55) confirmed that staff did not document repositioning of patient #'s 2 and 4 on the facility rounding log per Policy # H-PC10-003.