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Based on policy review, review of product information for a hospital bed, medical record review, and staff interview, the facility failed to ensure all immobile patients were turned and/or repositioned to prevent skin break down for one of ten patient medical records reviewed (Patient #2). The census was 251.

Findings include:

Review of the facility's policy titled Pressure Ulcers: Guidelines for Prevention and Treatment, implemented 08/14, revealed under Intervention/Activity and Mobility "Turn every 2 hours and as needed".

Review of the medical record for the Patient #2 was completed on 07/06/17. Patient #2 came to the emergency department (ED) via Emergency Medical Services (EMS) on 05/10/17 due to cardiac arrest at her/his residence. The patient had been asystolic (absent a pulse/heart beat) when EMS arrived. The patient received medication, was defibrillated, and the patient was intubated. Upon arrival to the hospital, the patient was sent to the catheterization lab and was diagnosed with mid left anterior descending artery disease. The patient was transferred to the intensive care unit and remained unresponsive. The patient was discharged to a long term care hospital on 05/24/17.

On 05/13/17, the patient was placed on specialized bed to assist with pressure relief. Review of the product information for the bed revealed it helped with pressure relief to help prevent and treat pressure ulcers. There was nothing in the product information that stated that the patient did not need to be turned and repositioned when in this bed.

Further review of the Patient #2's record revealed she/he was seen by a Wound, Ostomy, Continence Care nurse on 05/16/17. The patient had developed a deep tissue injury (DTI) to the coccyx that was 4 centimeters (CM) by 1.2 cm. The area was dark purple and over a bony prominence. The skin surrounding the wound was intact. The nurse's recommendations included a topical ointment to be applied to the area three times per day and as needed. Staff were to continue turning and repositioning the patient from side to side every two hours and as needed.

Review of the medical record for Patient #2 revealed she/he was not turned or repositioned every two hours on 05/13/17 at 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM; 05/14/17 at 10:00 AM, 12:00 PM 4:00 PM, and 6:00 PM; 05/15/17 at 6:00 AM, 10:00 PM, 2:00 PM, and 10:00 PM; 05/16/17 at 2:00 PM, 4:00 PM, 6:00 PM, and 10:00 PM; 05/17/17 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM; 05/18/17 at 8:00 AM and 10:00 AM; 05/19/17 at 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM; 05/20/17 at 4:00 PM and 6:00 PM; 05/24/17 at 10:00 AM. There was no documentation as to why the patient was not turned or repositioned.

An interview with Staff A and Staff B on 07/06/17 at 10:05 AM confirmed Patient #2 developed a DTI to the coccyx, which was discovered on 05/16/17. Staff A confirmed that although the patient had a pressure relieving bed, the patient still needed to be turned and repositioned.

An interview with Staff A, Staff B and other administrative staff on 07/06/17 at 1:30 PM and 3:00 PM confirmed Patient #2 was not turned every two hours according the the facility's policy. Further interview confirmed there was no documentation as to why the patient was not turned or repositioned.

This substantiated substantial allegation OH00091769.