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Based on record review and interview, the facility failed to ensure that there was an adequate number of registered nurses to perform patient care on 6 East IMU unit for 9 of 26 shifts reviewed.

Findings Included:

Record review of facility "6 East IMCU - Patient Care Assignment Sheets" dated 8/20/25 through 09/01/2025. The following days/shifts demonstrate there were only 3 Registered Nurses assigned to the unit (1 Clinical Nurse Coordinator (CNC) and 2 Registered Nurses. This resulted in 2 Registered nurses having 5 patients in their assignment. The sheets reflected:
8/22/25 PM Shift "1 CNC and 2 RNs". There were 12 patients.
8/23/25 PM shift "1 CNC and 2 RNs." There were 12 patients.
8/24/25 AM shift "1 CNC and 2 RNs." There were 12 patients.
8/25/25 PM shift "1 CNC and 2 RNs." There were 12 patients.
8/29/25 PM shift "1 CNC and 2 RNs." There were 12 patients.
8/30/25 AM and PM shifts. "1 CNC and 2 RNs." There were 12 patients.
8/31/25 AM and PM shifts. "1 CNC and 2 RNs." There were 12 patients.

Record review of facility policy titled "Nursing Staffing Plan", last revised 6/3/2025, stated "Each department director/manager does the following:contract agreements
1.Each unit will develop a staffing plan (matrix) using standards established by the Texas Board of Nurse Examiners and Nursing Code of Ethics as well as recommendations by professional organizations such as AACN, AANN, APNA, SPN, and AWHONN. The staffing matrix will set the minimum staffing levels for the typical patient population." It further stated "If available staff are not sufficient to safely care for the patients on the unit, the unit Director, Nursing Supervisor or AOS will take the following actions to secure additional staff: a. Utilize staff on-call
b.Reassign staff from another unit, c.Secure staff from an approved staffing agency
d.Request staff work additional hours."

Interview with Nursing Director Staff ID # 70 on 9/3/2025 at 11:45 am. She confirmed the unit utilized a "staffing matrix" for staffing. She stated that the unit frequently stays full with 12 patients. The staffing grid for 12 patients on the unit is
1 clinical nurse coordinator, who is usually a free charge nurse, and 3 Registered nurses and 1 patient care technician.

Interview with Nursing Operations Director Staff ID # 73 on 9/3/25 at 1:45 pm. She confirmed the facility is aware of staffing needs on the 6 East IMU unit and has been actively working to address it. She stated the facility had opened an IMU in an adjacent unit to help with capacity issues and some of the core staff had been routed to this unit. She reported the facility utilizes internal float pool and internal contracts to assist with staffing shortages. In addition, staff can be re-distributed from other medical/surgical and ICU areas, if needed.

Based on observation, record review and interview, the facility failed to ensure that nursing staff provided and/or documented turning and/or repositioning every 2 hours per institutional and national standards, in 3 out of 3 current patient records reviewed who had pressure related wounds (Patient ID #s 1, 15 and 16).

Findings Included:

Observation 9/3/2025 at 11:15 am on 6E Nursing Unit of EMR with Charge Nurse Staff ID # 75 for Patient ID #1, 15 and 16. She confirmed it is a unit practice to turn and reposition patients every 2 hours, unless there is a contraindication to do so. She displayed the Meditech EMR record for Patient ID #1, 15 and 16. She stated it is a unit protocol to turn patients every 2 hours. She stated there is not a place for these turning and repositioning activities to be charted by bedside staff and therefore she could not locate evidence of this occurring. She confirmed that Patient ID #1, 15 and 16 all were current patients on the unit with 1 or more pressure injuries.

Record review 9/3/2025 at 11:20 am of the Charge Nurse Report sheet for 6E IMU. Patient ID #1, 15 and 16 were listed as having current wounds and staff were perfroming wound care.

Record review of facility document titled "Clinical practice guidelines for pressure injuries and at-risk wounds", last revised 5/12/25, stated "B. Nursing Interventions: Based on assessment findings, appropriate interventions will be initiated that align with NPIAP guidelines and will be documented in the patient's plan of care." It further stated "STANDARD OF CARE: 1. Comprehensive skin assessments will be recorded in the electronic medical record. 2. High-risk areas (e.g., sacrum, heels) will be assessed. 3. Preventative measures will be initiated based on risk level.
PRESSURE INJURY INTERVENTIONS: 1. Maintaining skin integrity through cleaning, moisturizing, and protection. 2. Promoting mobility and minimizing shear/friction through appropriate repositioning. 3. Utilizing interdisciplinary collaboration for nutrition support and complex wound management."

Record review of NPIAP (National Pressure Injury Advisory Panel) guidelines, version February 25, 2025, stated "R7. We reocmmend that either repositioning at the two hourly or three hourly intervals could be implemented for most individuals at risk of pressure injuries, if they are also on an appropriate pressure redistribution full body support surface."

Record review of Patient ID # 1, 15 and 16 with Informaticist Staff ID # 81. She confirmed she was unable to locate the frequency or side of turning and repositiong in their medical records. She confirmed that registered nurses would document under the "Routine Daily Care" section near the beginning of their shift, corresponding to their shift assessment. The line item stated "Activity - turn." She confirmed there was no documentation of the planned or actual frequency of this turning for Patient ID #1, 15 and 16.

Interview 9/3/2025 at 09:00 am with Manager of Wound Care Team Staff ID # 78. He confirmed the facility practices would include turning and repositioning every 2 hours, low air loss mattress utilization, use of wedges and positioners, possible use of Prevalon boots as well as other technologies for wound pressure prevention strategies. He confirmed he was unable to ascertain frequency of turning for inpatients Patient ID #1, 15 and 16.