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Based on medical record review, policy review and staff interview, the facility failed to follow physician orders to turn patients to prevent the development of new skin breakdown and to promote healing and failed to provide any evidence of assistance with feeding and acceptance of meals. (A-0395)

Based on medical record review, policy review and staff interview, the facility failed to follow physician orders to turn patients to prevent the development of new skin breakdown and to promote healing for two patients (#2 and #4) and failed to provide any evidence of assistance with feeding and acceptance of meals for one patient (#4). These deficient practices affected two patients (Patient #2 and #4).

Findings include:

1. The medical record for Patient #4 revealed an admission on 11/15/24 after a fall. A nursing skin assessment was completed on admission 11/15/24 at 4:00 PM, listing scattered abrasion and bruising noted on the back with preventative foam placed to the sacrum. Nursing notes further stated this patient was unable to move either leg and was positioned with assistance. Orders were placed to turn this patient every two hours and to float heels.

Review of the flowsheets revealed Patient #4 was turned to the right side on 11/16/24 at 8:00 AM and was not turned to the left side until 6:00 PM. On 11/18/24 at 6:00 PM Patient #4 was turned to the right side until 11/19/24 at 6:00 AM when the patient was turned to the back. The next documentation found in the medical record was on 11/20/24 at 8:00 PM indicating this patient was turned to the right side. Notes on 11/21/24 at 8:00 PM stated this patient was sitting upright with no documentation of turning again until 8:00 AM, when she was turned to the left side. Notes on 11/23/24 at 8:00 PM stated this patient turned themselves, with the next documentation of positioning on 11/24/24 at 8:00 AM showing the patient was turned onto the back. The next documentation of re-positioning was recorded on 11/26/24 at 10:00 AM stating the patient was up in the chair.

Review of the wound care notes dated 11/25/24 revealed Patient #4 had a documented a deep tissue injury to the sacrum with measurements of 7 centimeters (cm) by 5 cm and 0 for depth. Notes further stated this deep tissue injury was not present on admission.

Review of the facility policy titled "Pressure Injury Prevention Clinical Practice Guidelines," dated 07/05/24, revealed a risk assessment should be completed upon admission to identify patients at risk for developing pressure injuries. Reposition for optimal offloading/pressure redistribution of bony prominence and reduce time in a sitting position. Clean skin routinely ad promptly after incontinence and protect with appropriate moisture-barrier product. Document interventions taken to prevent pressure injury in the electronic medical record and if the patient refuses.

Interview on 12/04/24 at 3:00 PM staff A verified the finding of not turning this patient every two hours per order with the development of a sacral wound.

2. The medical record for Patient #2 was reviewed on 12/04/24. Patient #2 was admitted on 09/24/24 at 5:23 AM per squad due to altered mental status and elevated blood sugars. The history and physical documented this patient had a history of chronic obstructive pulmonary disease (COPD), Type II diabetes and left sided residual paralysis from a stroke which occurred in 2020. This patient was admitted to the Intensive Care Unit (ICU) on an insulin drip with blood glucose levels in the 400s.

Patient #2 was assessed by the wound care nurse on 09/25/24 at 9:50 AM. Notes listed a Stage 3 wound to the sacrum, which was present on admission measuring 4.4 cm by 1.8 cm by 0.3 depth. Orders were received to cleanse with soap and water, apply Hydrofiber silver foam, and to change every other day and as needed for soiling.

Orders were written on 09/25/24 at 11:47 AM to turn every two hours, cleanse skin after soiling and to maintain heels off the bed.

The medical record revealed on 09/25/25 at 8:00 AM Patient #2 was turned to the right side with the next documentation of turning to the left side occurring 14 hour later at 10:00 PM. The patient remained on the left side until 4:00 AM on 09/26/24, six hours after turning. On 09/27/24 at 2:00 PM this patient was turned to the right then to the left at 5:00 PM. No documentation was found this patient was turned the rest of their stay, with a discharge home on 10/07/24.

Review of progress notes from the wound care nurse on 09/30/24 at 12:16 PM revealed the dressing was changed with measurements of 4.4 cm by 3 cm by 0.3 cm.

Patient #2 returned to the hospital on 10/17/24 at 8:23 PM with a diagnosis of left sided facial drop with a Stroke alert called.

This record revealed on 10/18/24 at 5:30 AM Patient #2 was turned to the left side and then to the right side at 10:00 AM, where they remained until 4:00 PM. On 10/19/24 at 4:00 AM Patient #2 was turned to the left side on with the next documentation of turning 14 hour later when the patient was turned to the left. On 10/20/24 at 6:00 PM Patient #2 was turned to the right side and not repositioned again until 10:00 AM on 10/21/24, 16 hours later.

Interview on on 12/04/24 at 3:00 PM Staff A verified the Patient #2 was not turned every two hours.

Additionally, Patient #2 had orders dated on 10/01/24 for Patient #2 to have a dysphasia pureed moderately thick diet and for a total assist with feeds. On 10/02/24 the record contained no intake amounts or any documentation to identify this patient ate. Notes on 10/03/24 stated the patient completed 51-75% of the meal at 9:38 AM and 12:41 PM. No other documentation was found in the medical record of any oral intake amounts or assistance with eating. The patient discharged home on 10/07/24.

Patient #2 was re-admitted on 10/17/24 with a pureed moderately thick diet reordered on 10/18/24. Feedings were recorded on 10/18/24 at 9:15 AM and 12:50 PM showing intake of diet was 76-100 %. There was no documentation of the dinner meal intake on 10/18/24. On 10/19/24 there was no documentation of any oral intake. No oral intake or assistance provided with meals was documented on 10/21/24 or 10/23/24, with this patient discharged home on 10/24/24 with family.

Interview on 12/05/24 at 3:55 PM per phone call with a resident physician revealed they spoke with Patient #2's family on 10/24/24 at approximately 4:15 PM. The family was very upset, stating when they came to visit the food tray was cold in the room and no one ever fed their mother.

Interview on 12/05/24 at 4:30 PM the Registered Dietician (RD) stated the patient's history tells staff if the patient needs assistance with meals. The RD stated this facility does not have a policy related to feeding patients further stating it's in the orders.

Interview on 12/04/24 at 3:00 PM, Staff A verified the findings of no evidence Patient #2 was provided an oral intake and assisted with eating was not identifiable in the medical record. Staff A stated this facility does not have a policy in place it's just a given and should be documented.