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Based on interviews, the review of medical records and other documents, nursing staff failed to implement facility's policy to assure the prevention and treatment of pressure ulcers. This finding was noted in 3 of 8 medical records (MRs) reviewed (MR #1, #2, and #3).

Findings include:

Review of MR #1 on 5/5/15 noted the patient was admitted on 11/26/14 status post (S/P or status after) fall at home. Nursing documentation on 11/27/14 at 2100 noted the skin to be intact. Prior to 12/15/14 there was no evidence documented that the patient in MR #1 had started to or had developed a pressure ulcer. On 12/15/14 at 8:00 AM, nursing documentation noted a stage II pressure ulcer to the left buttock, measuring 1.5 centimeters (cm) x 1.5 cm. The mobility flow sheets dated 12/31/14, 1/1/15, 1/2/15, 1/4/15, 1/5/15, 1/20/15, 1/21/15, 1/24/15 and 1/25/15 failed to indicate the patient was consistently turned and positioned every two hours as per facility's policy. Also on 12/2/14 to 12/4/14 the patient was noted to be on all four positions (position right, position supine, position left and position prone) all at the same time. The failure to timely identify the pressure ulcers, the lack of turning and positioning every two hours as per facility policy, and the documentation that indicated that the patient had been in all four positions at the same time were brought to the attention of Staff #2.

Review of MR #2 on 5/5/15 noted this patient arrived to the Emergency Department (ED) on 3/24/15 with a chief complaint of cough, nausea, vomiting, dizziness and chest pain. The past medical history is significant for Hypertension (HTN), Cushing Syndrome (a collection of signs and symptoms due to prolonged exposure to cortisol, such as, high blood pressure, abdominal obesity, reddish stretch marks, a round red face, a fat lump between the shoulders, weak muscles, weak bones, acne, and fragile skin that heals poorly), Cerebrovascular Accident (CVA), Intracerebral Hemorrhage (ICH), S/P Craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain), and End Stage Renal Disease (ESRD). On 3/24/15, the skin is noted to be intact. On 4/22/15 a stage II superficial pressure ulcer is noted to the buttock measuring 7 cm x 6 cm. Prior to 4/22/15 there was no evidence documented that the patient in MR #2 had started to or had developed a pressure ulcer. This was brought to the attention of Staff #2.

The patient in MR #3 is a 76 year-old female with multiple medical conditions who was admitted on 4/7/15 for treatment of sepsis secondary to Urinary Tract Infection. The initial nursing assessment on admission on 4/7/14 notes the presence of multiple pressure ulcers; sacral, Stage III, 9 centimeters (cm) x 6 cm x 7 cm with 3 cm tunneling; a right hip unstageable ulcer 9 cm x 5 cm with eschar (a piece of dead tissue that is cast off from the surface of the skin) and dark black edges; and a buttock stage II.

The patient had no care plan on admission that outlines the nursing care to be provided for the pressure ulcers. Consequently, measures to prevent pressure ulcer as well as treatment of existing ulcers were inconsistently implemented. The patient was not consistently repositioned every two hours from admission on 4/7/15 to discharge on 4/13/15. In addition, there was no treatment indicated in the medical record for the third pressure ulcer located on the buttocks.

The facility's policy titled "Maintenance of Skin Integrity" last revised in February 2012 notes, "based on nurse's initial assessment, a plan of care is developed to reflect preventive measures or pressure sore treatment. The policy further notes that patient with potential skin impairment would be turned every two hours.

At interview with Staff #1 on 5/5/15 at 11:45 AM, she stated the patient ought to have been turned every two hours and the turning schedule documented in the electronic medical record.

On 5/6/15 at 12:55 PM, Staff #2 verified the patient's care plan did not address all the care needs identified by nursing on admission of the patient. The care plan for prevention and treatment of pressure ulcer was not developed.