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Based on medical record review, policies, and interviews, the nursing staff failed to document reports of treatment and nursing notes that indicated a patient with impaired skin integrity was repositioned every two hours.

Review of the "Prevention of Pressure Injuries" policy #PS-48, published 3/5/20, revealed that all skin surfaces are assessed, including skeletal prominences (bony areas), on admission and every shift. A Skin Assessment form is used for the assessment. The nurse refers to a computerized nursing plan of care for Impaired Skin Integrity. Findings are documented through a computerized documentation system and department-specific forms and flowsheets.

Review of the "Nursing Plan of Care for High-Risk Pressure Injury Prevention" policy revealed that for patient with a Braden score of 17 or less, the patient is to be repositioned every two hours, and more frequently if necessary.

Review of the medical record for P#2 revealed a Plan of Care was initiated by the Registered Nurse on 7/14/21 at 4:26 a.m. and included interventions for Skin Integrity. The interventions for Skin Integrity were as follows:

Assess and document risk factors for pressure ulcer development on admission.
Assess and document skin integrity and dressing/incision, wound bed, drain sites, and surrounding tissue once per shift, and as needed.
Implement wound care per orders.
Initiate pressure ulcer bundle, as indicated
Provide education to patient/caregivers regarding wound care and infection control.
Follow Standard of Care for Maintenance of Skin Integrity.

Review of the Daily Care and Safety Nursing flowsheets revealed the nursing staff failed to document that P#2 was repositioned every two hours on the following dates:

7/18/21 at 10:00 p.m. until 7/19/21 at 6:00 a.m.
7/19/21 at 10:00 p.m. until 7/20/21 at 6:00 a.m.
7/21/21 at 10:00 a.m. until 7/21/21 at 6:00 p.m.
7/22/21 at 12:00 p.m. until 7/22/21 at 6:00 p.m.
7/22/21 at 10:00 p.m. until 7/23/21 at 8:00 a.m.
7/24/21 at 10:00 a.m. until 7/24/21 at 6:00 p.m.
7/25/21 at 10:00 a.m. until 7/25/21 at 6:00 p.m.
7/25/21 at 10:00 p.m. until 07/26/21 at 3:00 a.m.

During an interview with the Director of Nursing (DON) on 9/14/21 at 1:35 p.m., the DON stated two nurses conducted an initial skin assessment on each patient upon admission. The DON also stated, the nurses also conducted a Braden Score Assessment and assigned a number (the lower number, the greater the risk) to help identify if a patient is at risk for skin breakdown. The DON further stated, if a patient were at risk of skin breakdown, the nurses would follow the guidelines based on the score, including repositioning the patient. The DON stated, repositioning and wound dressing changes were documented in the patient's medical record.

During an interview with Care Partner (CP) EE on 9/14/21 at 1:50 p.m. in the Board Room, CP EE stated patients who were not able to reposition themselves were assisted with repositioning every two hours.

During an interview with the manager of the Telemetry unit, Registered Nurse (RN) CC on 9/14/21 at 2:10 p.m., in the Board Room, RN CC stated patients with a high risk for skin breakdown were identified and placed on a repositioning schedule. RN CC stated that patient repositioning should be a team effort between the nurse and care partner. RN CC stated the nurses rounded on patients, alternating every other hour with the patient's care partners; patients would were repositioned every two hours. RN CC stated it was the nurse's responsibility to document in the medical record when a patient was repositioned. RN CC stated staff assignment sheets were provided with patient care listed, including wound care. RN further stated, each nurse would be given a copy of the assignment sheets, and a copy would also be located at the nursing station. RN CC stated hourly tasks would be broken down, and the nurse would document that tasks were completed. RN CC also stated, repositioning patients were not included on the electronic worklist.