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Based on observation, interviews and clinical record and policy review it was determined the Registered Nurse failed to supervise and evaluate nursing care for the implementation of turning and repositioning for 5 ( #1, #2, #3, #8, #9) of 10 sampled patients out of a census of 49 patients.

Findings include:

1. Patient #1 had wound care orders dated 3/28/13 at 12:53 a.m. for the patient to be turned and repositioned every 2 hours using a foam wedge for positioning. A review of the patient's turning and repositioning documentation revealed the following:
On 3/28/13 the patient was left sitting in a chair for approximately 8 hours and 22 minutes from 12:00 p.m. to 8:22 p.m.
On 3/28/13 at 8:22 p.m. to 3/29/13 at 6:48 a.m. the patient was left to reposition herself, approximately 10 hours.
On 3/29/13 the patient was left sitting up in the chair for approximately 7 hours from 1:46 p.m. to 8:16 p.m.
On 4/5/13 the patient was left to reposition herself for approximately 22 hours from 12:00 a.m. to 10:55 p.m.
On 4/6/13 the patient was left to reposition herself from 2:55 a.m. to 6:55 a.m.
On 4/14/13 the patient was left sitting in a chair for approximately 6 hours from 1:45 p.m. to 7:55 p.m.
On 4/15/13 the patient was placed on her right side for approximately 3 hours from 8:21 p.m. to 11:44 p.m.
On 4/20/13 the patient was placed on her left side for 3 hours from 6:51 a.m. to 10:00 a.m.

2. Patient #2's history and physical revealed the patient was bedridden and unresponsive. A review of the patient's turning and repositioning documentation revealed the following:
On 4/26/13 the patient was positioned on her left side for approximately 4 hours from 4:37 p.m. to 8:14 p.m.
On 4/28/13 the patient was positioned in a supine position for approximately 14 hours from 4:00 p.m. to 6:15 a.m.
On 5/4/13 the documentation indicated the patient was repositioning herself at 6:15 a.m., 8:00 a.m., 10:00 a.m., at 12:07 p.m., and at 3:53 p.m.

3. Patient #3's physical therapy evaluation revealed the patient was assessed as a maximum assistance for bed mobility. A review of the patient's turning and repositioning documentation revealed the following:
On 5/16/13 the patient was in a supine position for approximately 7 hours from 6:35 a.m. to 1:46 p.m.
The patient was in a supine position from 6:32 p.m. until 10:30 p.m., approximately 4 hours.
On 5/19/13 the patient was positioned onto his right side at 2:02 a.m. and then repositioned onto his left side at 10:00 a.m., approximately 8 hours. At 4:00 p.m. it was documented the patient was turned to his left side, approximately 6 hours.

4. Patient #8's history and physical revealed the patient did not follow commands. A review of the patient's turning and repositioning documentation revealed the following:
On 5/22/13 the patient was placed on her left side for approximately 4 hours from 4:00 a.m. to 8:00 a.m. On 5/24/13 the patient was placed in a supine position for approximately 4 hours from 6:00 a.m. to 10:00 a.m. On 5/25/13 the patient was positioned onto her left side for approximately 4 hours from 8:00 a.m. to 12:00 p.m. From 12:00 p.m. to 8:06 p.m. the patient was positioned in a supine position for approximately 8 hours.
On 5/26/13 the patient was positioned in a supine position for approximately 14 hours from 6:03 a.m. to 8:06 p.m.

5. Patient #9's History and Physical dated 5/18/13 revealed diagnosis that included Multiple Sclerosis with secondary paraplegia and Osteomyelitis of the pubic bone.
An interview was conducted the patient on 6/3/13 at approximately 11:10 a.m., observations during the interview revealed the patient was lying on her back and not able to move her lower extremities. Further observations revealed a dressing on the right foot and both feet resting on the mattress. The patient stated she was not able to turn herself.

An interview was conducted on 6/3/13 at approximately 11:20 a.m. with the Certified Nursing Assistant, who was assigned to the care of the patient on 6/3/13. The interview revealed the patient was not able to move the lower extremities and could assist somewhat with the upper extremities in turning but could not do it on her own.

An interview was conducted on 6/3/13 at approximately 11:40 a.m. with the Licensed Practical Nurse assigned to the care of the patient. She revealed the patient could not turn herself.

A review of the patient Care Plan dated 5/18/13 at 10:00 p.m. revealed the patient was to be repositioned every 2 hours. A review of the patient Care Plan dated 5/20/13 at 9:00 p.m. revealed the patient's heels were to be elevated off the bed.

Observations of the patient on 6/3/13 at approximately 11:10 a.m. revealed the patient was on her back with both heels lying on the mattress.

Review of the nursing documentation dated 5/24/13 at 10:00 a.m. and 4:00 p.m. indicated the patient turned herself.

The Director of Quality Management confirmed the above findings during the observations and record reviews on 6/3/13 at approximately 11:30 a.m. and 4:45 p.m.

A review of the facility's policy "Pressure Ulcer Prevention and Treatment" policy #H-WC-01-001, release date 02/2013, page 3 of 6, section Prevention Components, paragraph 5, revealed preventative and healthy skin interventions are utilized and may include, but not limited to "repositioning at intervals determined per patient risk level and condition. A minimum of every 2 hours for those determined to be at a moderate or high risk and off loading with elevation of extremity, wedges, pillows, etc, as indicate".