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Based on document review and interview, the facility failed to ensure standards of nursing care met for patient positioning in 7 of 11 ( 1, 2, 3, 4, 6, 9 and 11's) patient medical records (MR) reviewed.

Findings include:

1. Review of facility policy, Pressure Injury (Ulcer) Prevention and Treatment, last revised, 06/2018, (Policy ID: 4857480) indicated, Prevention: for patients that are high risk for skin breakdown (such as Braden 18 or below or Braden Q 16 or below) and medical condition allows... While in bed assess patients who are able to turn independently are turning and document position changes a minimum every two hours. Encourage patients to turn a minimum every two hours and document position changes. Patients, who are unable to turn independently, assist with reposition changes a minimum every two hours and document position changes... While in a chair encourage patients who are able to turn independently and document position changes a minimum every two hours. Patients who are unable to turn independently, assist with reposition changes a minimum every two hours and document position changes.

2. Review of facility, Standard of Care & Documentation Frequency for Critical Care indicated, Assessments/Interventions (real time) Q (every) 2 hours Position Changes (musculoskeletal interventions).

3. Review of patient 1's Adult Assessment Intervention 9/27/2018, at 11:44 am, by N14 (Registered Nurse) and N15 (Registered Nurse) indicated, Skin [WDL Definition: No abnormal color; no abnormality in temperature, moisture, turgor, integrity; no pressure ulcer] WDL except incision(s). Braden Risk Assessment Braden Score 17. Review of patient 1's MR discharge summary dictated 10/07/2018, at 06:48 pm, by S4 (Physician Assistant) indicated patient 1 had coronary artery bypass grafting on September 27, 2018. Patient was taken from the operating room to the Intensive Care Unit in critical but stable condition. Postop (postoperative) day 5, the patient was transferred to the Progressive Care Unit. Wound/Skin Evaluation by N13 (Registered Nurse) signed on 10/01/2018, at 16:46 pm, indicated patient 1 has bright red/deep maroon color intact skin on bilateral buttock and extended to Coccyx area. There is a 1.4 cm (centimeter) X 1.4 cm in size intact blister on soft tissue of left buttock. 10.8 cm X 10 cm pressure wound, suspected deep tissue injury. Patient is on a Dovin mattress, to be turned every 2 hrs (hours) side to side ... Review of patient 1's MR lacked indication of position change every two hours including the following. 9/27/2018, at 18:00, supine, 20:00, supine. 9/28/2018, 06:00, no entry indicated, 12:00, right side, 14:00, lacked indication of position (right side, supine, left side), 20:00, up in chair, 22:00, up in chair (lacked indication of position change). 9/29/2018, at 00:00, supine, 02:00, supine, 04:00 supine, 06:00 supine, 10:00, lacked indication of position (right side, supine, left side), 12:00, lacked indication of position (right side, supine, left side), 14:00, lacked indication of position (right side, supine, left side), 18:00, lacked indication of position (right side, supine, left side), 20:00, lacked indication of position (right side, supine, left side), 22:00, no entry indicated, 9/30/2018, 00:00 lacked indication of position (right side, supine, left side), 02:00 no entry indicated, 04:00, lacked indication of position (right side, supine, left side).

4. Interview on 4/4/2019, at approximately 11:00 am, with N6 (Manager Patient Care Services) confirmed patient 1's MR lacked documenting of position changes every 2 hours while on Critical Care Unit.

5. Review of patient 2's MR indicated patient had coronary artery bypass surgery on September 27, 2018. Patient was taken from the operating room to the Cardiac ICU (Intensive Care Unit) in critical, but stable condition. Review of patient 2's MR lacked documentation of position changes every 2 hours including the following. 9/27/2018, 20:00 lacked indication of position (right side, supine, left side), 22:00 lacked indication of position (right side, supine, left side). 9/28/2018, 00:00, lacked indication of position (right side, supine, left side). 9/28/2018, 16:39, supine, 17:00, lacked indication of position (right side, supine, left side), 18:22 supine, 19:17 supine, 22:36, lacked indication of position (right side, supine, left side), 00:36, lacked indication of position (right side, supine, left side), 02:36, lacked indication of position (right side, supine, left side), 04:50, lacked indication of position (right side, supine, left side), 05:50,lacked indication of position (right side, supine, left side) 08:04, lacked indication of position (right side, supine, left side).

6. Interview on 4/4/2019, at approximately 1:08 pm, with N4 (Quality Consultant) confirmed patient 2's MR lacked documentation of position changes every two hours. N4 confirmed documentation received on positioning was while patient was in Critical Care.

7. Review of patient 3's MR indicated patient had coronary artery bypass grafting on September 5, 2018. Patient was transferred to Intensive Care Unit. Review of patient 3's MR lacked documentation of position changes every 2 hours including, 9/6/2018, 00:00 left side, 02:00, no entry indicated, 04:00 left side, 12:00 up in chair, 14: 00 up in chair, 16:00 supine, 18:00 supine.

8. Interview on 4/4/2019, at approximately 1:40 pm, with N4 confirmed patient 3's MR lacked documentation of position changes every two hours. N4 confirmed documentation received on positioning was while patient was in ICU.

9. Review of patient 4's MR indicated patient had coronary artery bypass grafting on September 5, 2018. Patient was transferred to surgical ICU (Intensive Care Unit). Review of patient 4's MR lacked documentation of position changes every 2 hours including, 9/6//2018, 02:00, 06:00 and 08:00, no entry indicated.

10. Interview on 4/4/2019, at approximately 2:07 pm, with N4 confirmed patient 4's MR lacked documentation of position changes every two hours. N4 confirmed documentation received on positioning was while patient was in ICU.

11. Review of patient 6's MR indicated patient had coronary artery bypass grafting on September 7, 2018. Patient was transferred to CV (Cardiovascular) Critical Care Unit. The patient was transferred Step-Down Unit on September 13, 2018. Review of patient 6's MR lacked documentation of position changes every 2 hours including, 9/8/2018, 20:00 lacked indication of position (right side, supine, left side) , 9/9/2018, 16:00, lacked indication of position (right side, supine, left side), 9/10/2018, 08:00, lacked indication of position (right side, supine, left side).

12. Interview on 4/4/2019, at approximately 2:30 pm, with N4 confirmed patient 6's MR lacked documentation of position changes every two hours. N4 confirmed documentation received on positioning was while patient was in ICU.

13. Review of patient 9's MR indicated patient had coronary artery bypass grafting on September 20, 2018. Patient was taken to ICU (Intensive Care Unit) in stable condition. Patient was transferred out of ICU on postop day # 4. Review of patient 9's MR lacked documentation of position changes every 2 hours including, 9/21,2018, 02:00, supine, 04:00, supine, 06:00 supine, 08:00, supine, 10:00, no entry indicated, 12:00 supine, 14:00, no entry indicated, 16:35 supine.

14. Interview on 4/4/2019, at approximately 3:46 pm, with N4 confirmed patient 9's MR lacked documentation of position changes every two hours. N4 confirmed documentation received on positioning was while patient was in
Critical Care.

15. Review of patient 11's MR lacked documentation of position changes every 2 hours including, 4/5/2019, 06:00, lacked indication of position (right side, supine, left side), 08:00, lacked indication of position (right side, supine, left side).

16. Observation on 4/5/2019, at approximately 9:41 am with N6, patient 11 was in room 3919 on the Intensive Care Unit.

17. Interview on 4/5/2019, at approximately 10:00 am, with N6, confirmed patient 11 was admitted to floor on 4/2/2019, at approximately 13:41, following a coronary artery bypass graft procedure. Patient 11's MR lacked documentation of position changes every two hours.

Based on document review and interview, the facility failed to ensure discharge instructions for follow up wound care needs in 1 of 10 (patient 1's) medical records (MR) reviewed.

Findings include:

1. Review of facility policy, Discharge Planning, Last Revised 12/2018, (PolicyStat ID 5595571), indicated effective discharge planning addresses the patient's needs for continuing care to meet physical and psychosocial needs.

2. Review of patient 1's evaluation by N13 (Registered Nurse) signed on 10/01/2018, at 16:46 pm, indicated patient 1 has bright red/deep maroon color intact skin on bilateral buttock and extended to Coccyx area. There is a 1.4 cm (centimeter) X 1.4 cm in size intact blister on soft tissue of left buttock. 10.8 cm X 10 cm pressure wound, suspected deep tissue injury. Patient is on a Dovin mattress, to be turned every 2 hrs (hours) side to side ...Wound/Skin Evaluation by N13 (Registered Nurse) signed on 10/01/2018, at 16:34 pm, indicated ...Applied no sting barrier wipe to skin then a Sacral Allevyn foam drg (dressing). To change every 3 days & WOC (Wound Ostomy Care) team to follow up on pt (patient).

3. Review of patient 1's MR lacked indication of discharge instructions for wound care.

4. Interview on 4/4/2019, at approximately 11:37 am, with N3 (Director of Quality) confirmed no wound care instruction given at discharge.

5. Interview on 4/4/2019, at approximately 11:58 am, with N8 (Wound Ostomy Care Team) confirmed orders for wound care were not given to patient 1 at discharge.