HospitalInspections.org

Based on document review and interview, the registered nurse failed to implement fall prevention care and wound prevention care as required by facility policy for one (1) of five (5) medical records reviewed (N1).
Findings included:
1. Facility policy " Fall Prevention " , last reviewed/revised 11-2010, page 2, required " On admission the patient is screened by the admitting nurse for fall risk using the Fall Risk Screening Tool or the EMR Fall/Risk Assessment " and on page 3 that "a score of greater than or equal to 10 = At Risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls. The At Risk for Fall Interventions may include, but are not limited to:
use of a "risk for falls" sign/device...
use of a "remember to call for help" sign posted in the patient's room...
use of Bed Alarms/Chair Alarms
avoid use of full-length side rails
move patient closer to Nurses Station
Rehab. evaluation and treatment as appropriate
pharmacy review of medications for fall risk potential
use of low bed
select suitable chairs that have armrests or another appropriate geriatric chair
consider family staying, or changes needed in staffing"

2. Facility policy "Wound Prevention" , last reviewed/revised 06-2011, page 1, "Patients scoring 3 or less in any Braden Risk sub-scale will be deemed at risk for that sub-scale...Prevention interventions are to initiated in each sub-scale scoring 3 or less...
(for the activity category of the Braden Risk assessment 1=bedfast; confined to bed; 2=chairfast; ability to walk severely limited or nonexistent... 3= walks occasionally... 4=walks frequently....) A. Mechanical Load/Support Surface/Pressure Relieving Devices. i. Turn, when patient is unable to turn self, every two hours according to facility routine and regardless of type surface or bed".

3. Facility policy " Medical Record Documentation " , last reviewed/revised 01-2010, page 1, item 4, required " After rendering care, document as soon as possible".

4. Review of medical record of N1 on 7-3-2012 indicated that:
a. upon admission on 4-24-2012, N1's admission fall risk score was 12 and N1 was identified as being "at risk" for falls per facility policy.
b. the first documentation of the use of a bed exit alarm for N1 was on 4-30-2012; 6 days after admission.
c. upon admission on 4-24-2012, N1's Braden score was 12 and therefore N1 was at high risk for skin breakdown per facility policy.
d. N1's admission Braden score included a sub-scale of 1 for activity (1=bedfast; confined to bed; 2=chairfast; ability to walk severely limited or nonexistent... 3= walks occasionally... 4=walks frequently....) A sub-score of 1 in the activity category per policy was less than a score of 3 and mandated the implementation of preventative interventions per facility policy.
e. on 5-10-12 at 6 AM, 5-14-12 at 6 AM, and 5-17-12 at 6 AM, the medical record lacked documentation that N1 had been turned on the every 2 hour hour schedule in accordance with facility policy.
5. During interview with S2 on 7-3-2012 at 4:00 PM, S2:
a. verified the findings in the medical records.
b. confirmed N1 was assessed upon admission on 4-24-12 as "At risk" for a fall and S2 confirmed that the nurse should have immediately implemented a bed exit alarm.
c. confirmed that a bed exit alarm was not documented as done until 4-30-12 in N1's medical record, and that the 6 day delay was not in accordance with facility expectation of nursing care interventions.
d. confirmed that 2 hour turn should have been performed based on N1's admission Braden score of 12 with a sub-score of 1 in the activity category (1=bedfast).

e. confirmed that N1 ' s medical record lacked documentation on 3 occasions (5-10-12 at 6 AM, 5-14-12 at 6 AM, and 5-17-12 at 6:00 AM) that N1 had been turned, and that the lack of documentation in the medical record was not in accordance with facility policy.

f. confirmed N1's nursing care plan in relation to fall risk care and skin care was not implemented in accordance with facility policy.

Based on document review and interview, the facility failed to assure a complete medical record was retained to include photographs of non-intact skin required per policy for one (1) of five (5) medical records reviewed (N1).
Findings included:
1. Facility policy in the Skin and Wound Care Management Manual, "Photographing of Wounds Guideline" , last reviewed/revised 06-2011, page 1, required that upon patient admission the Wound Care Coordinator "would be notified to coordinate patient care and photograph the patient ' s wound(s). Initial photographs should be printed and placed in the patient's chart under 'wound' section and further digital images should also be stored electronically on the facility secure drive designated by the IS department " .

2. Facility policy " Medical Record Documentation " , last reviewed/revised 01-2010, page 1, item 4, required " After rendering care, document as soon as possible ".

3. On 7-3-2012 during review of medical record of N1:
a. the initial nursing assessment and the physician's history and physical indicated that upon admission N1 had an area of non-intact skin in the left buttock.
b. the photographs taken at the first wound care consultation for N1 on 4-25-2012 lacked documentation of a photograph of the left buttock non-intact skin area.
4. During interview with S3 on 7-3-2012 at 4:00 PM, S3:
a. verified the findings in the medical records to include the lack of documentation of an initial assessment photograph of N1's left buttock area of non-intact skin.
b. stated that a photograph of N1's left buttock non-intact skin should have been printed and placed in the medical record as soon as practicable after taken on 4-25-2012.
c. could not explain how the printed copy of the above photograph and the electronic back up required per facility policy could not be located.