HospitalInspections.org

Based on interview and record review the hospital does not have a well-organized nursing service, in that, the nurses failed to follow physician orders to turn every 2 hours for 1 of 1 (Patient#2) of 10 patients sampled.

Finding included:

Patient #2 was admitted on 04/30/19 with a sacral decubitus. On 05/01/19 there was a physician's order to turn the patient every 2 hours. A review of the record reflected The Risk for impaired skin/tissue integrity: Nurses notes reflected ..." on 05/02/19 from 0600until 2130 the patient remained positioned on her right side ...on 05/03/19 from 0000 until 0600 the patient remained position on her right side. From 0600 until 1440 the patient remained positioned on her left side and from 1440 until 2100 the patient remained in the supine position. From 2100 until 05/04/19 at 0205 the patient remained on her left side. On 05/05/19 from 0400 until 0800 the patient remained on her left side. From 1810 until 2200 the patient remained on her left side. On 05/06/19 at 0200, 0400, and 0717 it is charted the patient repositioned herself, this patient is not capable of repositioning herself. On 05/06/19 from 1600 until 2026 the patient remained on her right side. On 05/07/19 from 1600 until 2200 the patient remained on her right side. On 05/08/19 from 0400 until 0800 the patient remained in the supine position. On 05/09/19 from 0400 until 0800 the patient remained on her left side. And from 1800 until05/10/19 at 0010 the patient remained on her right side. On 05/10/19 from 2200 until 05/11/19 at 0200 the patient remained on her left side. From 0600 until 0955 the patient remained in the supine position. From 0955 until 1400 the patient on her left side. From 1453 until 1858 the patient remained on her left side. On 05/12/19 from 0000 until 0400 the patient remained in the supine position. On 05/13/19 at 2348 until0554 the patient remained on her right side. On 05/14/19 from 0800 until 1408 the patient remained in the supine position. On 05/15/19 from 0012 until 0420 the patient remained on her right side. From 0420 until 1000 the patient remained in the supine position. On 05/16/19 from 0800 until 1600 the patient remained in the supine position. On 05/17/19 from 0635 until 1109 the patient remained on her right side. On 05/18/19 from 0800 until 1400 the patient remained in the supine position. From 1553 until 2045 she remained on her right side. On 05/19/19 from 1758 until 2200 the patient remained in the supine position. On 05/20/19 from 2330 until 05/21/19 at 0400 the patient remained in the supine position. From 1200 until 1600 the patient remained on her right side and from 1800 until 2130 the patient remained on her right side. On 05/22/19 from 1600 until 2000 the patient remained in the supine position. From 2151 until 05/23/19 at 0420 the patient remained on her right side. On 05/23/19 from 1400 until 2000 the patient remained on her right side. On 05/25/19 from 0600 until 1002 the patient remained on in the supine position. From 1002 until 1600 the patient remained on her left side. On 05/26/19 from 0200 until 0600 the patient remained in the supine position. From 0800 until 1400 the patient remained in the supine position.

During a chart review on 09/24/19 ending at 1205 Personnel #3 confirmed that Patient #2 was not being turned every 2 hours as ordered by the physician.