HospitalInspections.org

Based on administration interviews and
medical record reviews, the hospital
failed to document the required initial
Braden Risk Assessment Scores
in 1 of 10 records, noted in P5's
medical record.

Failure to measure and document the
patient's Braden Risk Assessment Scores
within 8-24 hours of admission can result
result in not meeting the patient's needs
and implementing the patient's care plan.




Findings:

1. On Wednesday 05/18/2011 at 1400
the investigator review the patient's
(P5's) electronic medical records.
The physician's documentation noted
that the patient was an 85 year old who
had fallen at home. The patient complained
of right hip pain and was alert and oriented.
The physician admitted the patient on
05/16/2011 at 1400 to the medical surgery
unit located on the second floor for
treatment of anemia.

2. The investigator reviewed the nursing
assessment entries on the patient's
electronic data base. The review determined
that the patient's initial Braden Risk
Assessment Scores were missing on the
record for the dates of 05/16/2111 and
05/17/2011.

3. The review continued to reveal
that nursing documented the patient's
initial Braden Risk Assessment scores
on 05/18/2011 at 1013. Also, the patient's
Braden Score measured 18 which is a normal
score. The nursing staff assessed and
documented the patient's initial
Braden Score 45 hours after the
patient was admitted to the unit.

4. The Director of Clinical Services reported
that nursing service should have assess and
document the patient's initial Braden Scores
on 05/16/2011 within 8 hours of admission.
The director also reported that nursing should
have documented the patient's Braden Score
on 5/17/2011 within 24 hours of admission,
meeting the hospital's standards.

5. The director continued to explained they were
sending out daily electronic alerts to nurses to
remind them to record this data by 1900. This
was a new expectation for nurses developed
by nursing service administration and it was not
finalized at this time.

6. The nursing service failed to implement
the hospital's Braden Risk Assessment
standards that were developed to determine
when patients could be or were
at risk for pressure ulcers.