HospitalInspections.org

Based on document review, and interview the facility failed to ensure the nursing staff followed the policy and procedure related to turning a high risk patient at a minimum of every two (2) hours, and completing an evaluation related to the patient's ability to use a standard call light for one (1) of ten (10) patients closed medical records (MR's) reviewed. (Patient # 10)

Findings include:

1. Review of the hospital policy entitled, "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds", policy number H-PC 10-003, effective date 08/2012, indicated pressure ulcer prevention interventions are utilized and may include but not limited to "high risk patients are turned at a minimum of every two (2) hours. A Braden Scale Risk Assessment is completed upon admission then daily. The purpose of the scale is to help health professionals assess a patient's risk of developing a pressure ulcer by examining the following six (6) criteria: sensory perception, moisture, activity, mobility, nutrition, and friction & shear. Each category is rated on a scale of one (1) to four (4) except friction and shear which is rated on a one (1) to three (3) scale. This combines for a possible total of twenty-three (23) points, with a higher score meaning a lower risk of developing a pressure ulcer and vice versa". This policy was released 06/2016.

2. Review of the hospital policy entitled, "Patient Call Devices", policy number H-PC 09-009, effective date 06/1992, indicated that all patients understand how to use and have access to call devices at all times. The admission nurse should "evaluate the patient's ability to use the standard call light".

3. Review of closed medical record # 10 indicated the following:
A. The patient was a 41 y/o admitted to LT # 1 on 10/30/2017 with the following diagnoses: bilateral pneumonia of the lungs with pseudomonas, advanced multiple sclerosis with contracture, sacral decubitus ulcer, oropharyngeal dysphagia, severe protein calorie malnutrition, and functional quadripresis. The patient was discharged from LT # 1 on 12/06/2017.
B. The initial order written on 10/31/2017 by MS # 1 (Pulmonologist), indicated to reposition the patient Q2h (every two (2) hours) following schedule: at midnight, 2 am, 4 am, 6 am, 8 am, 10 am, 12 pm, 2 pm, 4 pm, 6 pm, 8 pm, and 10 pm.
C. The initial nursing wound assessment completed on 10/31/2017 by RN # 11 (Registered Nurse), indicated the patient to be turned and repositioned every two hours.
D. The Integumentary Assessment completed on 10/31/2017 by RN # 12 (Registered Nurse), indicated the patient's Braden's scale score was an eleven (11). This score indicated the patient was at a high risk for developing additional pressure ulcers, and was documented as such.
E. The MR lacked nursing documentation related to turning/repositioning the patient on the following dates and times:
1. On 11/01/2017 at 2 am, 4 pm, 8 pm, and 10 pm.
2. On 11/07/2017 at 6 pm and 10 pm.
3. On 11/09/2017 at 2 am, 4 am, and 6 pm.
4. On 11/18/2017 at 2 pm, 4 pm, and 6 pm.
5. On 11/20/2017 at 2 am, 4 am, 6 am, 8 am, 10 am, 12 pm, and 8 pm.
6. On 11/21/2017 at midnight, 2 am, 4 am, and 6 am.
7. On 11/23/2017 at 2 am, 4 am, 8 am, 10 am, 12 pm, 2 pm, 4 pm, and 6 pm.
8. On 11/25/2017 at midnight, 2 am, and 4 pm.
9. On 11/26/2017 at 8 am, 12 pm, and 4 pm.
10. On 11/27/2017 at 12 pm, 2 pm, 4 pm, and 6 pm.
11. On 11/28/2017 at midnight, 2 am, 4 am, 6 am, 12 pm, 4 pm, and 6 pm.
12. On 11/30/2017 at midnight, 6 am, 4 pm, and 6 pm.
F. The MR lacked any documentation that the patient's ability to use a standard call light was evaluated, or what type of call light the patient had available.

4. On 12/29/2017 at approximately 9:50 am with administrative staff member A # 2 (Chief Clinical Officer), confirmed that the patient was at high risk on the Braden Risk Assessment scale for developing additional pressure ulcers.

5. On 12/29/2017 at approximately 10:15 am with administrative staff member A # 2 and A # 7 (Director of Rehab), confirmed that according to LT # 1's policy, the patient's MR was lacking the documentation related to an evaluation on the patient's ability to use a standard call light. The "touch call lights are not special order or have to be signed out".

6. On 12/29/2017 at approximately 12:20 pm with administrative staff member A # 2 and A # 1 (Director of Quality Management), confirmed that according to LT # 1's policy, the patient's MR was lacking documentation the patient, who was at high risk, was being turned and repositioned every two (2) hours.