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Based on interview and record review it was determined the facility failed to ensure an effective process was established for the prompt resolution of patient grievances for one of ten sampled patients (Patient #1). A review of the facility complaint/grievance form revealed the facility's Chief Nursing Officer (CNO) received a complaint/grievance from Patient #1's family related to the patient's care at the facility. However, documentation revealed the facility failed to conduct an investigation of the complaint that included documentation of interviews with nursing staff and the physician, or that included a review of the medical record, a written outcome of the investigation, or that correspondence with the results of the investigation was provided to the patient's family member or representative.

The findings include:

Review of the facility policy titled "Patient Grievance/Complaint Policy," dated 07/29/13, revealed a patient grievance is a formal or informal written or verbal complaint that is made to the facility by a patient or patient's representative when a patient issue cannot be resolved on the spot by staff present for all verbal and written complaints of abuse and neglect. "If the staff member or department director believes that the grievance involves quality of care issues, compliance issues or may result in legal action, he/she will refer the grievance to the Risk Management for investigation. Within 7 days of receipt of patient grievances, Strategic Services, Director, or Risk Management shall contact the patient or patient representative to resolve the grievance. If the grievance needs further investigation, Strategic Services will send a postcard to inform the patient representative of the need for further investigation and the expected time frame for resolving the grievance."

A review of Patient #1's medical record revealed the facility admitted the patient on 12/09/13 with diagnoses of Pneumonia and Respiratory Failure. However, Patient #1 expired at the facility on 12/27/13 due to a decline in medical condition.

Review of the facility's Complaint/Grievance Form dated 12/20/13 at 2:05 PM revealed Patient #1's family member voiced a complaint to the CNO on 12/20/13 that facility staff had not responded to requests for assistance with the patient in a timely manner. According to documentation, the patient's family member went to the nursing station and requested assistance with Patient #1 but was denied assistance because "family was in the room." Continued review of documentation on the Complaint/Grievance Form revealed the patient's family member believed Patient #1 was in "crisis" due to the lack of care provided by facility staff. Based on documentation, the CNO informed the family member the facility would investigate the complaint and would conduct a medical record review, conduct interview with facility staff, and "process improvement for the future." The documentation also revealed the patient's family member was informed that they (the family member) might not be "here" when the facility conducted the investigation related to the reported concerns. Documentation on the grievance form also revealed the patient's family member "understood" the facility's "plan of action."

However, a review of the facility's investigation revealed the facility failed to provide documentation that verified the facility conducted a review of Patient #1's medical record, and failed to document interviews were conducted with facility staff and the patient's physician during the course of the investigation. In addition, based on documentation, the facility failed to follow up with the patient's family member of the actions taken by the facility as a result of the investigation.

Interview with Patient #1's family member on 01/29/14 at 9:45 AM confirmed he/she had voiced a complaint to the facility's CNO on 12/20/13 regarding the slow response from facility staff when they had requested assistance, on numerous occasions, with the patient during the morning hours of 12/20/13. Patient #1's family members stated he/she informed the CNO he/she had requested assistance with the patient due to a decline in the patient's medical condition. Patient #1's family member further stated that nursing staff "would not come to the room and look at the patient, they were sitting at the nursing station eating breakfast." The interview further revealed the facility had planned to discharge the patient on 12/20/13, the day the family member had voiced the complaint to the CNO but, due to a decline in the patient's medical condition, the patient was transferred to the facility's Critical Care Unit. Interview with the patient's family member also revealed the CNO stated she would "get back" with the patient's family member with the results of the facility's investigation of the family member's complaint. However, the family member stated the facility failed to contact him/her, verbally or in writing, to inform him/her of the results of the facility's investigation.

Interview with the CNO on 01/29/14 at 11:45 AM revealed Patient #1's family member came to her office on 12/20/13 and voiced a complaint about the quality of care provided to Patient #1. The CNO stated the family member was concerned the patient was in a "crisis" situation and they went to the nursing unit to assess the patient. At that time, it was determined the patient had a rapid heart rate, which had not been the result of lack of care by staff and the family member stated "they understood." In addition, the CNO acknowledged she informed the patient's family member that she would review the medical record and interview nursing staff, and she stated she informed the family the investigation of complaints took a "period of time" and that "they may not still be in the facility when that took place." The CNO stated the patient's family member stated he/she "understood" and "I trust you." According to the CNO, she conducted an investigation in which she made rounds on the floor, reviewed the staffing schedule, and interviewed nursing staff but was unable to substantiate the complaint. The CNO stated she thought the facility's reported plan of action had resolved the patient's family member's concerns at the time, had not considered the concerns a "grievance," and, as a result, had not reported the outcome of the facility's actions to the patient's family member.

Based on interview and record review it was determined the facility failed to ensure a Registered Nurse supervised and/or evaluated the nursing care for three of ten sampled patients (Patients #1, #2, and #6). A review of nurse's notes and flow sheets for Patient #1 revealed Registered Nurses failed to ensure staff provided assistance with turning and repositioning, and incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown for Patient #1. In addition, interview, record review, and review of the facility's policy revealed the facility failed to ensure nursing staff developed and kept current a nursing care plan for one of ten sampled patients (Patient #1). A review of a nursing assessment conducted on the day of Patient #1's admission, 12/09/13, revealed the patient was incontinent of bowel and bladder and wore an absorbent brief. In addition, the assessment revealed the patient's skin was "within normal limits," except for erythema (redness of the skin) to the coccyx. A review of Patient #1's care plan revealed facility staff failed to develop a care plan to address the area of erythema to the patient's coccyx at the time of admission in an effort to prevent worsening of the patient's impaired skin integrity until 12/26/13, seventeen days after admission to the facility; and failed to develop a care plan to address the "purple, intact and nonblanchable area" to the bridge of the patient's nose until 12/26/13, three days after the area on the patient's nose was observed.

Refer to A0395 and A0396.

Based on interview and record review it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for three of ten sampled patients (Patients #1, #2, and #6). A review of nurse's notes and flow sheets revealed Registered Nurses failed to ensure staff provided assistance with turning and repositioning, and failed to provide incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown for Patients #1, #2, and #6.

The findings include:

Interview on 01/27/14 at 1:15 PM with the Executive Director of Nursing revealed the facility did not have a written policy related to the frequency that staff was to assist and/or provide turning and repositioning of dependent patients.

A review of the National Pressure Ulcer Advisory Panel's document titled Pressure Ulcer Prevention Points, not dated, revealed bedbound persons should be repositioned every two hours for prevention of pressure sores and skin breakdown. Further review of the document revealed patients should have an established bowel and bladder program to ensure the skin was cleansed at the time of soiling or very soon after.

1. A review of Patient #1's medical record revealed the facility admitted the patient on 12/09/13 with diagnoses of pneumonia and respiratory failure. A review of Patient #1's admission nursing assessment, dated 12/09/13 at 2:45 PM, revealed the patient was incontinent of bowel and bladder, wore absorbent briefs, and his/her skin condition was assessed to be within normal limits except for erythema (redness of the skin) to the coccyx.

Based on a review of Patient #1's medical record, staff failed to develop a plan of care to address the patient's ability/inability to turn and reposition him/herself, or the frequency staff was to monitor Patient #1 for incontinence care based on the facility's assessment that Patient #1 was incontinent of bowel and bladder.

A review of an Activity of Daily Living (ADL) flow sheet revealed staff failed to turn and reposition Patient #1 every two hours. Based on documentation, staff failed to turn and reposition Patient #1 from 4:52 PM until 11:00 PM on 12/12/13 (a timeframe of 6 hours and 8 minutes); from 11:00 PM on 12/13/13 until 3:00 AM on 12/14/13 (a timeframe of 4 hours); between the hours of 7:00 PM on 12/15/13 and 7:00 AM on 12/16/13 (a timeframe of 12 hours); or from 4:00 PM until 7:00 PM on 12/16/13 (a timeframe of 3 hours).

In addition, it could not be determined, based on a review of documentation, that facility staff had monitored Patient #1 for incontinence every two hours in accordance with the National Pressure Ulcer Advisory Panel's standards of practice. A review of the Intake and Output (I&O) flow sheets for Patient #1 revealed staff provided incontinence care to Patient #1 two times on 12/10/13 between 4:00 AM and 4:51 PM (a timeframe of 12 hours and 51 minutes); four times between 12/11/13 at 3:30 PM and 12/12/13 at 3:00 AM (a timeframe of 11 hours and 30 minutes); four times between 12/13/13 at 3:12 PM and 12/14/13 at 4:36 AM (a timeframe of 13 hours and 24 minutes); one time between 12/14/13 at 3:21 PM and 12/15/13 at 5:00 AM (a timeframe of 13 hours and 39 minutes); two times between 12/16/13 at 4:59 PM and 12/17/13 at 5:00 AM (a timeframe of 12 hours and 1 minute); three times on 12/17/13 between 5:00 AM and 4:29 PM (a timeframe of 11 hours and 29 minutes); two times on 12/18/13 between 5:00 AM and 4:22 PM (a timeframe of 11 hours and 22 minutes); and four times between 12/19/13 at 3:00 PM and 12/20/13 at 5:00 AM (a timeframe of 14 hours).

A review of a nursing assessment dated 12/23/13 at 8:00 AM, 14 days after the patient's admission to the facility, revealed Patient #1 had an area on the bridge of the nose that was "purple, intact, and non-blanchable." In addition, the assessment revealed Patient #1 had excoriation (raw, irritated skin) to the right and left buttocks.

A review of documentation revealed staff that provided care to Patient #1 during the patient's admission to the facility from 12/09/13 until 12/20/13 included Patient Care Attendant (PCA) #1, PCA #2, Registered Nurse (RN) #1, RN #4, and Unit Manager (UM) #1. However, interviews conducted with PCA #1 on 01/28/14 at 1:20 PM, PCA #2 on 01/28/14 at 3:15 PM, RN #1 on 01/28/14 at 11:00 AM, and RN #4 on 01/28/14 at 2:10 PM revealed they did not recall Patient #1 and could not provide any information related to the patient's care.

Interview on 01/29/14 at 10:23 AM with UM #1 revealed Patient #1 should have been turned and repositioned or encouraged to turn and reposition every two hours. Further interview revealed Patient #1 should have been monitored for incontinence every two hours.

2. A review of Patient #2's medical record revealed the facility admitted the patient on 01/10/14 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. A review of Resident #2's History and Physical, dated 01/10/14, revealed the patient did not have any skin issues or open wounds.

A review of Patient #2's Care Plan, "Risk for and/or Impaired Skin Integrity," dated 01/10/14, revealed facility staff had developed interventions that included to assist/turn the patient every two hours and to monitor the patient for incontinence care every two hours. Further review of the care plan revealed on 01/19/14, nine days after Patient #2's admission to the facility, staff noted the patient had redness to the coccyx area that was slow to blanch. Based on the assessment, staff added interventions to the care plan on 01/20/14 that included the use of a soft foam dressing and ointment to the patient's coccyx and buttocks.

A review of Patient #2's nursing assessment, dated 01/28/14 at 2:00 PM, revealed Patient #2 had developed an open area to the left buttock. Continued review of documentation revealed facility staff cleansed the area with normal saline, applied an ointment, and covered the area with a soft foam dressing.

A review of Patient #2's ADL flow sheet, dated 01/28/14, revealed no documented evidence Patient #2 was turned and repositioned from 3:00 AM until 7:00 AM (a timeframe of 4 hours). Continued review of the ADL flow sheet, dated 01/28/14, revealed no documented evidence Patient #2 was turned and repositioned from 7:00 AM until 11:00 AM (a timeframe of 4 hours).

3. A review of the medical record for Patient #6 revealed the facility admitted the patient on 01/23/14 with diagnoses that included Urinary Tract Infection and Urosepsis.

A review of a nursing assessment dated 01/23/14 revealed the patient was incontinent of bowel and had an indwelling urinary catheter in place.

A review of Patient #6's Care Plan revealed on 01/24/14, facility staff had identified Patient #6 was at "Risk for and/or Impaired Skin Integrity." Continued review of the Care Plan revealed, based on the patient's risk for impaired skin integrity, staff had developed interventions that included to assist and/or turn the patient every two hours and to monitor the patient for incontinence every two hours.

However, a review of an Intake and Output (I&O) sheet dated 01/23/14 through 01/29/14, a timeframe of six days, revealed no documentation that staff had assessed and/or provided incontinence care to Patient #6 every two hours as planned.

Interview on 01/28/14 at 1:20 PM with PCA #1 revealed patients that are dependent on staff to turn them should be turned and repositioned every two hours. According to PCA #1, nursing staff or PCAs could turn and reposition the patient; however, it was the PCA's primary responsibility. PCA #1 stated each time a staff person turned/repositioned a patient they should enter the turning/repositioning into the computerized documentation system. The interview further revealed incontinence care or toileting should also be conducted/offered every two hours and documented. The PCA stated staff was to document information related to the patient's I&O on a paper document located near the door to the patient's room, and enter the documentation into the computer at the end of the shift.

Interview on 01/28/14 at 3:15 PM with PCA #2 revealed turning and repositioning should be conducted or encouraged for patients that self-turn every two hours and documented in the computer on the Activities of Daily Living (ADL) flow sheet. Continued interview revealed incontinence care or toileting should also be conducted/offered every two hours, documented on the I&O sheet located by each patient's door, and documented in the computer at the end of each shift. Further interview revealed "only" the number of times a patient's incontinence brief was changed or the number of times the patient was toileted was documented, and not the specific time the activity took place.

Interview on 01/28/14 at 11:00 AM with RN #1 revealed staff should turn and reposition patients that are unable to turn and reposition themselves every two hours, and should encourage those patients that are capable of turning to reposition themselves every two hours. Further interview revealed staff should provide incontinence care every two hours to those patients that were incontinent, and should offer to provide assistance with toileting for the patients that were independent every two hours. RN #1 stated she was not responsible for ensuring a resident was turned and repositioned or that incontinence care was provided.

Interview on 01/28/14 at 2:10 PM with RN #4 revealed all patients should be turned, repositioned, and provided incontinence care or toileting every two hours. Continued interview revealed that if she observed a patient that required incontinence care, she would notify a PCA. Further interview revealed PCAs provided patients with turning and repositioning and were also responsible for entering documentation of the turns and repositioning into the computer.

Interview on 01/29/14 at 10:23 AM with UM #1 revealed PCAs were required to make rounds on patients every two hours and to turn and reposition patients that needed assistance, and were also to provide incontinence care or toilet patients every two hours. The interview further revealed the staff that provided care was to enter the information related to the provision and/or assistance with ADLs into the computerized documentation system. The interview further revealed the UM made rounds on the unit "often" to ensure care was provided. UM #1 stated she had not identified problems with staff not providing care to patients.

Interview on 01/29/14 at 11:45 AM with the Chief Nursing Officer (CNO) revealed the RNs were responsible to ensure all care, including turning and repositioning and incontinence care, was provided to patients. Further interview revealed the CNO frequently was on the floor to make rounds to ensure all patient care needs were met.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure nursing staff developed and kept current a nursing care plan for one of ten sampled patients (Patient #1). A review of a nursing assessment conducted on the day of admission, 12/09/13, revealed Patient #1 was incontinent of bowel and bladder and wore an absorbent brief. In addition, the assessment revealed the patient's skin was "within normal limits," except for erythema (redness of the skin) to the coccyx. A review of Patient #1's care plan revealed facility staff failed to develop a care plan to address the area of erythema to the patient's coccyx at the time of admission in an effort to prevent worsening of the patient's impaired skin integrity until 12/26/13, seventeen days after admission to the facility; and failed to develop a care plan to address the "purple, intact and nonblanchable area" to the bridge of the patient's nose until 12/26/13, three days after the area on the patient's nose was observed.

The findings include:

A review the facility policy titled "Patient Assessment/Reassessment: Nursing, Nutrition, Social Services, Behavioral Health, revised on 02/06/13, revealed an individualized Plan of Care would be developed, documented, and provided in coordination with the patient, family, and other designated individual. Further review of the policy revealed the plan would be updated as appropriate following changes in the patient's condition.

A review of Patient #1's medical record revealed the facility admitted the patient on 12/09/13 with diagnoses of Pneumonia and Respiratory Failure. A review of Patient #1's admission nursing assessment, dated 12/09/13 at 2:45 PM, revealed the patient was incontinent of bowel and bladder, wore an absorbent brief, and the patient's skin was assessed to be within normal limits except for erythema to the coccyx.

A review of Patient #1's wound documentation flow sheet, dated 12/22/13 at 8:00 PM, revealed an area to the bridge of the nose described as "clean, dry, pink, red, purple and intact" with an intervention of a soft foam dressing in place. Further review of the wound documentation flow sheet, dated 12/23/13 at 8:00 AM, revealed an area to the bridge of the nose described as "dry" and "purple" with measurements of 0.4 centimeters (cm) length and 0.3 cm in width with an intervention of soft foam dressing in place.

A review of Patient #1's nursing assessment, dated 12/23/13 at 8:00 AM, revealed an area to the bridge of the nose described as "purple, intact and nonblanchable" and "excoriation" to the right and left buttocks.

A review of Patient #1's care plan revealed facility staff failed to develop a care plan to address the area of erythema to the patient's coccyx at the time of admission in an effort to prevent worsening of the patient's impaired skin integrity until 12/26/13, 17 days after admission to the facility; and failed to develop a care plan to address the "purple, intact and nonblanchable area" to the bridge of the patient's nose until 12/26/13, three days after the area on the patient's nose was observed.

Interview on 01/28/14 at 2:35 PM with Registered Nurse (RN) #5 revealed a care plan should have been developed and implemented at the time of Patient #1's admission to the facility that addressed the patient's risk for impaired skin integrity. According to RN #5, a care plan should have also been developed and implemented when the area to the patient's nose and buttock areas were initially observed.

Interview on 01/28/14 at 1:00 PM with Unit Manager (UM) #2 revealed facility staff should develop a care plan when a patient was assessed to have risk factors for skin breakdown. The interview further revealed an Impaired Skin Integrity care plan should have been initiated when the area on Patient #1's nose and the excoriation on the resident's buttocks were initially observed.

Interview on 01/29/14 at 10:23 AM with UM #1 revealed facility staff should have developed a care plan, with interventions, at the time they assessed Patient #1 to be incontinent. Further interview revealed if facility staff assessed a patient to have impaired skin integrity, the care plan should be updated with new interventions in an effort to prevent worsening of the patient's impaired skin integrity.

Based on interview and record review it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for three of ten sampled patients (Patients #1, #2, and #6). A review of nurse's notes and flow sheets revealed Registered Nurses failed to ensure staff provided assistance with turning and repositioning, and failed to provide incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown for Patients #1, #2, and #6.

The findings include:

Interview on 01/27/14 at 1:15 PM with the Executive Director of Nursing revealed the facility did not have a written policy related to the frequency that staff was to assist and/or provide turning and repositioning of dependent patients.

A review of the National Pressure Ulcer Advisory Panel's document titled Pressure Ulcer Prevention Points, not dated, revealed bedbound persons should be repositioned every two hours for prevention of pressure sores and skin breakdown. Further review of the document revealed patients should have an established bowel and bladder program to ensure the skin was cleansed at the time of soiling or very soon after.

1. A review of Patient #1's medical record revealed the facility admitted the patient on 12/09/13 with diagnoses of pneumonia and respiratory failure. A review of Patient #1's admission nursing assessment, dated 12/09/13 at 2:45 PM, revealed the patient was incontinent of bowel and bladder, wore absorbent briefs, and his/her skin condition was assessed to be within normal limits except for erythema (redness of the skin) to the coccyx.

Based on a review of Patient #1's medical record, staff failed to develop a plan of care to address the patient's ability/inability to turn and reposition him/herself, or the frequency staff was to monitor Patient #1 for incontinence care based on the facility's assessment that Patient #1 was incontinent of bowel and bladder.

A review of an Activity of Daily Living (ADL) flow sheet revealed staff failed to turn and reposition Patient #1 every two hours. Based on documentation, staff failed to turn and reposition Patient #1 from 4:52 PM until 11:00 PM on 12/12/13 (a timeframe of 6 hours and 8 minutes); from 11:00 PM on 12/13/13 until 3:00 AM on 12/14/13 (a timeframe of 4 hours); between the hours of 7:00 PM on 12/15/13 and 7:00 AM on 12/16/13 (a timeframe of 12 hours); or from 4:00 PM until 7:00 PM on 12/16/13 (a timeframe of 3 hours).

In addition, it could not be determined, based on a review of documentation, that facility staff had monitored Patient #1 for incontinence every two hours in accordance with the National Pressure Ulcer Advisory Panel's standards of practice. A review of the Intake and Output (I&O) flow sheets for Patient #1 revealed staff provided incontinence care to Patient #1 two times on 12/10/13 between 4:00 AM and 4:51 PM (a timeframe of 12 hours and 51 minutes); four times between 12/11/13 at 3:30 PM and 12/12/13 at 3:00 AM (a timeframe of 11 hours and 30 minutes); four times between 12/13/13 at 3:12 PM and 12/14/13 at 4:36 AM (a timeframe of 13 hours and 24 minutes); one time between 12/14/13 at 3:21 PM and 12/15/13 at 5:00 AM (a timeframe of 13 hours and 39 minutes); two times between 12/16/13 at 4:59 PM and 12/17/13 at 5:00 AM (a timeframe of 12 hours and 1 minute); three times on 12/17/13 between 5:00 AM and 4:29 PM (a timeframe of 11 hours and 29 minutes); two times on 12/18/13 between 5:00 AM and 4:22 PM (a timeframe of 11 hours and 22 minutes); and four times between 12/19/13 at 3:00 PM and 12/20/13 at 5:00 AM (a timeframe of 14 hours).

A review of a nursing assessment dated 12/23/13 at 8:00 AM, 14 days after the patient's admission to the facility, revealed Patient #1 had an area on the bridge of the nose that was "purple, intact, and non-blanchable." In addition, the assessment revealed Patient #1 had excoriation (raw, irritated skin) to the right and left buttocks.

A review of documentation revealed staff that provided care to Patient #1 during the patient's admission to the facility from 12/09/13 until 12/20/13 included Patient Care Attendant (PCA) #1, PCA #2, Registered Nurse (RN) #1, RN #4, and Unit Manager (UM) #1. However, interviews conducted with PCA #1 on 01/28/14 at 1:20 PM, PCA #2 on 01/28/14 at 3:15 PM, RN #1 on 01/28/14 at 11:00 AM, and RN #4 on 01/28/14 at 2:10 PM revealed they did not recall Patient #1 and could not provide any information related to the patient's care.

Interview on 01/29/14 at 10:23 AM with UM #1 revealed Patient #1 should have been turned and repositioned or encouraged to turn and reposition every two hours. Further interview revealed Patient #1 should have been monitored for incontinence every two hours.

2. A review of Patient #2's medical record revealed the facility admitted the patient on 01/10/14 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. A review of Resident #2's History and Physical, dated 01/10/14, revealed the patient did not have any skin issues or open wounds.

A review of Patient #2's Care Plan, "Risk for and/or Impaired Skin Integrity," dated 01/10/14, revealed facility staff had developed interventions that included to assist/turn the patient every two hours and to monitor the patient for incontinence care every two hours. Further review of the care plan revealed on 01/19/14, nine days after Patient #2's admission to the facility, staff noted the patient had redness to the coccyx area that was slow to blanch. Based on the assessment, staff added interventions to the care plan on 01/20/14 that included the use of a soft foam dressing and ointment to the patient's coccyx and buttocks.

A review of Patient #2's nursing assessment, dated 01/28/14 at 2:00 PM, revealed Patient #2 had developed an open area to the left buttock. Continued review of documentation revealed facility staff cleansed the area with normal saline, applied an ointment, and covered the area with a soft foam dressing.

A review of Patient #2's ADL flow sheet, dated 01/28/14, revealed no documented evidence Patient #2 was turned and repositioned from 3:00 AM until 7:00 AM (a timeframe of 4 hours). Continued review of the ADL flow sheet, dated 01/28/14, revealed no documented evidence Patient #2 was turned and repositioned from 7:00 AM until 11:00 AM (a timeframe of 4 hours).

3. A review of the medical record for Patient #6 revealed the facility admitted the patient on 01/23/14 with diagnoses that included Urinary Tract Infection and Urosepsis.

A review of a nursing assessment dated 01/23/14 revealed the patient was incontinent of bowel and had an indwelling urinary catheter in place.

A review of Patient #6's Care Plan revealed on 01/24/14, facility staff had identified Patient #6 was at "Risk for and/or Impaired Skin Integrity." Continued review of the Care Plan revealed, based on the patient's risk for impaired skin integrity, staff had developed interventions that included to assist and/or turn the patient every two hours and to monitor the patient for incontinence every two hours.

However, a review of an Intake and Output (I&O) sheet dated 01/23/14 through 01/29/14, a timeframe of six days, revealed no documentation that staff had assessed and/or provided incontinence care to Patient #6 every two hours as planned.

Interview on 01/28/14 at 1:20 PM with PCA #1 revealed patients that are dependent on staff to turn them should be turned and repositioned every two hours. According to PCA #1, nursing staff or PCAs could turn and reposition the patient; however, it was the PCA's primary responsibility. PCA #1 stated each time a staff person turned/repositioned a patient they should enter the turning/repositioning into the computerized documentation system. The interview further revealed incontinence care or toileting should also be conducted/offered every two hours and documented. The PCA stated staff was to document information related to the patient's I&O on a paper document located near the door to the patient's room, and enter the documentation into the computer at the end of the sh