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Based on clinical record review, interview and policy and procedure review, it was determined the Facility failed to implement the Nursing Care Plan for 1 (Patient #2) of 15 (#1-#15) patients. Failure to turn the patient every two hours per the Nursing Care Plan and Skin Care Prevention and Ulcer/Wound Protocol allowed Patient #2 to develop a skin injury. The failed practice affected 1 (#2) of 15 (#1-15) patients. Findings follow:

A. Review of the Nursing Care Plan for Patient #2 revealed at 0613 on 06/22/13 RN #5 revised the Nursing Care Plan to include Turn every 2 hours and elevate heels.

B. Review of Patient #2's clinical record revealed he was not turned every two hours per the Nursing Care Plan and the Skin Care Prevention and Ulcer/Wound Protocol.
Review of the 06/20/13 nursing notes revealed Patient #2 was turned three times without mention of heels bridged or elevated on pillows. Review of the 06/21/13 nursing notes revealed Patient #2 was turned two times without mention of heels bridged or elevated on pillows. Review of the 06/22/13 nursing notes revealed Patient #2 was turned once without mention of heels bridged or elevated on pillows. Review of the 06/23/13 nursing notes revealed Patient #2 was turned two times and heels up on pillows at 0201 only. Review of the 06/24/13 nursing notes revealed Patient #2 was turned two times and heels up on pillows at 0800 only. Review of the 06/25/13 nursing notes revealed Patient #2 was turned two times without mention of heels bridged or elevated on pillows. Review of the 06/26/13 nursing notes revealed no documentation Patient #2 was turned or heels were bridged. Review of the 06/27/13 nursing notes revealed the patient was turned two times without mention of heels bridged or elevated on pillows. Review of the 06/28/13 nursing notes revealed Patient #2 was turned six times without mention of heels bridged or elevated on pillows. Review of the 06/29/13 nursing notes revealed the patient was turned once without mention of heels bridged or elevated on pillows. Review of the 06/30/13 nursing notes revealed Patient #2 was turned twice and heels up on pillows at 0536 and 0647.

C. The above clinical record review findings were verified by the Regulatory Specialist during clinical record review at 1415 on 07/17/13.

D. Review of the Skin Care Prevention and Ulcer/Wound Protocol revealed "Deep Tissue Injury Algorithm Appendix: Notify Physician, report any changes to MD (Medical Doctor), Assess wound each shift, measure weekly. Heel or Foot - Bridge heels off of bed with pillows, Monitor closely for changes in condition of wound. Intact skin - Keep pressure off of heels. Blood Blister - Keep blister intact. Clean with Dermal Wound cleanser, no sting peri-skin, cover with dry 4x4s, wrap with Kerlix daily, secure with tape. Bulleted points included Document wound, Care Plan Wound, Consult ET (enterstomal therapy) Nurse, Photograph wound, Turn q 2 hours, Assess support surface, and Nutritional." The Protocol was received from the Regulatory Specialist at 1015 on 07/16/13.