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Based on Medical Record (MR) review and interview, the facility nursing staff failed to implement the facility's policy and procedures for prevention, treatment and documentation for patients identified at high risk for pressure ulcers. This was evident in one (1) of nine (9) medical records reviewed.

This lapse in adhering to facility protocols, placed patients at risk of developing for pressure injuries.

Findings:

Review of MR for Patient #1 revealed the following: the patient was assessed on 6/3/19, with a Braden score of 9, a Stage four (4) ulcer on the sacrum, a stage two (2) ulcer on the right hand and excoriation on the chin. There was no documentation in the MR from 6/3/19 at 8:43 PM to 6/5/19 at 8:00 PM. indicating that the patient was turned and repositioned every two hours or a dressing change performed as per standard facility protocol.

These observations were made in the presence of Staff M, Nursing Informatics/ Education and Staff N, Wound Ostomy Coordinator, who confirmed these findings.

The facility policy and procedure titled " Pressure Injury: Prevention and Management" last revised November 11th, 2020 states: Risk assessment is done using the Braden Scale, a score of 18 or below is consider risk and prevention plan is initiated ...prevention intervention will include: (1) Pressure redistribution ...Patient with altered bed mobility will be turned and reposition in accordance with overall goals of care."

The facility's "Pressure Injury flow sheet," not dated, states: For "Stage 2 Pressure Injury- cleanse wound with cleanser on stream and pat dry (skintegrity), Duoderm q3 days and PRN, silicone foam dressing q3 days and PRN, zinc oxide and other. Stage 4 Pressure Injury-cleanse wound with wound cleanser on stream and pat dry (skintegrity), for dry wounds: hydrating dressing (skintegrity hydrogauze), for wet wounds: calcium alginate (Maxsorb) and other."