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Based on interview and record review, nursing staff failed to provide nursing care to 2 sampled patients (Patient one and Patient two) out of 30 sampled patients when:

1. Patent 1 was not turned every one and one half to two hours per physician orders.
2. Patient 2 was not turned every one and one half to two hours per physician orders.

These failures placed Patient 1 and Patient 2 at risk of developing a pressure injury or worsening pressure injures (localized damage to the skin and underlying soft tissue over a bony prominence or related to a medical or other device.).

Findings:

1. During a review of Patient 1's History and Physical (H& P), dated 6/12/24, Patient 1 was admitted for acute hypoxemic, respiratory failure (also known as type 1 respiratory failure, occurs when the body doesn't get enough oxygen from the respiratory system). Patient 1 had a Braden score (a clinically validated tool that allows nurses and other healthcare providers to reliably score a patient level of risk for developing a pressure injury) of 16 and had acquired an unstageable pressure injury to the nasal septum.

During a review of physician orders, dated 7/5/24, the physician order indicated to turn Patient 1 every one and one half to two hours ...

During an interview on 8/12/24 at 11:40 a.m. with Patient Care Staff (PCS), PCS stated they were responsible for turning patients every two hours. PCS stated patients that have a Braden score of 13 or 14, anything under 18 had to be turned every two hours.

During an interview on 8/12/24 at 11:45 with Assistant Nurse Manager, (ANM), ANM stated they provided care for patients with pressure injuries. ANM stated anybody with Braden score less than 18 was put on "Leaf" for monitoring. The ANM stated Leaf tells us when to turn the patients. The ANM stated there is a monitor at the desk. It has the time the patient should be turned and the position the patient is in.

During a record review of the nursing flow record , various dates, the nursing flow record indicated Patient 1 was not turned every one and one half to two hours per physician orders. Patient 1 was turned as follows: 6/19/24 turned at 3 a.m. 8:25 a.m., and 11:53 p.m., 6/20/24 turned at 8 a.m., 3:30 p.m., and 7:54 p.m., 6/21/24, turned at 2 a.m. 9:15 a.m., 2:25 p.m. The next turn was on 6/22/24 at 12 a.m., 8:50 a.m. not turned until 6/23/24 at 1 a.m., 12 p.m. and 4:05 p.m. 6/24/24 turned at 4 a.m., 9:14 a.m. and 4:30 p.m. Patient 1 should have been turned 12 times within 24 hours. Patient 1 was turned 16 times but should have been turned a total 72 times.

1. During a review of Patient 2's History and Physical (H& P)dated 8/11/24 the H&P indicated Patient 2 was admitted for weakness and mild Chronic Obstructive Pulmonary Disease ( a group of lung diseases that block airflow and make it difficult to breath) exacerbation(an acute increase in the severity of a problem, illness or bad situation) and a community acquired pressure injury, Stage ll ( partial thickness loss of skin with exposed skin) on sacrum/buttocks.

During a record review on 8/14/24 at 2:30 p.m., a review of the physician orders indicated to turn patient every one and one half to two hours and to position patient off of pressure area.

During a review of the nursing flow record, various dates, the nursing flow record indicated Patient 2 was ambulated 8/12/24 at 10 a.m., 8/13/24 Chair, 1:34 p.m., ambulated, no documentation until 6:34 a.m., ambulated and at 1:46 p.m., ambulated. There wasn't any documentation to support Patient 2 had been turned while in bed throughout his admission.

During a review of the facility Policy and procedure titled," Pressure Injury Prevention NCAL Regional Policy", dated 6/4/24, indicated, "Patient repositioning should occur at a minimum of every two hours for at risk patients." 6.4.5 Documentation: "All pressure injury risk assessment and prevention interventions will be documented in the medical record."