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Based on staff interview, medical record review, and policy and procedure reviews, the facility failed to follow their policy and procedure by neglecting to turn Patient #1 every two (2) hours during patient's hospital stay 09/11/2025 through 09/15/2025 for one (1) of (3) patient records reviewed; Patient #1.

Findings Include:

Interview with Registered Nurse (RN) #1 on 12/03/2025 at 9:55 a.m. confirmed Patient #1 did not have any skin breakdown or discolored areas on his buttocks area when she performed her admission assessment on 09/11/2025.

Review of Patient #1's medical record from transferring facility dated 09/07/2025 revealed patient had a Stage 1 (one) decubitus ulcer on his sacrum.

Review of Patient #1's medical record "Admission Care Assessment," completed 09/11/2025 at 5:10 p.m. by RN #1 revealed no documentation of wounds present on admission.

Review of Patient #1's medical record, "Plan of Care" revealed patient was to be monitored for impaired skin integrity, Braden Scale, turning and repositioning every two (2) hours.

Review of Patient #1's medical record "Turning and Repositioning Care Assessments," revealed patient was turned for the first time on 09/12/2025 at 8:25 p.m., missing 13 turning and repositioning times since his admission on 09/11/2025 at 5:10 p.m. Patient #1 was not turned and repositioned again until 09/13/2025 at 8:00 a.m., missing five (5) turning and repositioning times. Patient was turned on 09/15/2025 at 6:00 a.m. then was not turned again until his discharge at 2:20 p.m., missing three (3) turning and repositioning times. Facility staff failed to turn and reposition patient a total of 21 times during his admission.

Review of Patient #1's Wound Assessment from his home health nurse revealed Patient #1 was admitted to home health 09/20/2025 with one (1) Stage 4 (four) pressure injury to his left buttock, one (1) Stage 3 (three) pressure injury to his mid-sacral region, one (1) Stage 2 (two) pressure injury to his scrotum, and one (1) Stage 2 (two) pressure injury to his penis.

Review of the facility's Braden Scale revealed patients with scores of 15-18 are considered mild risk, scores of 13-14 are considered moderate risk, scores of 10-12 are considered high risk, and scores of less than or equal to nine (9) are considered severe risk. Review of Patient #1's Braden Scale Assessments and Scores revealed his Braden Scale ranged from 11-15 throughout his admission. Patient received a Braden Scale score of 11 one time, 12 three (3) times, 13 two (2) times, 14 two (2) times, and 15 one (1) time during his admission.

Review of facility's policy and procedure, "Skin Assessment, Documentation, and Treatment," NS.S.001, Last Approved 05/2025, revealed any patient scoring 12 or below on the skin integrity assessment or identified as at-risk during reassessment will have skin risk protocol implemented and patients should be repositioned every 2 (two) hours and as needed (PRN) for comfort.