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Based on interview and record review, the facility failed to ensure nursing staff followed the individualized plan of care for 1 (P-24) of 30 patients reviewed, resulting in the patient acquiring a pressure sore. Findings include:

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A-0396 - Failure to follow an individualized plan of care

Based on interview and record review, the facility failed to ensure nursing staff followed the individualized plan of care for 1 (P-24) of 30 patients reviewed, resulting in the patient acquiring a pressure sore. Findings include:

A record review of P-24's medical record on 12/11/2024 at 1215 revealed P-24 was admitted to the facility on 10/30/2024 and underwent emergent coronary artery bypass the same day. Records revealed the patient was intubated, sedated, and on strict bedrest with restrictions of turning from 10/30/2024 at 2000 to 10/31/2024 at 0400. P-24 was intubated from 10/30/2024 to 11/10/2024. P-24 activity level was noted to be complete bedrest until 11/10/2024. P-24 medical record revealed three new wounds documented on 11/2/2024 at 2005, "...right groin, scrotum, and buttock. The "buttock" wound was documented as "unable to visualize, dressing dry/intact, foam." No documentation could be located for identification, description, or interventions of the "buttock" wound prior to 11/2/2024 at 2005.

On 12/11/2024 at 1225 a review of P-24 "Plan of Care" revealed a "skin plan" was initiated on 10/31/2024 at 1500. On 11/4/2024 at 1354 a note from the Wound Ostomy Care Nurse, staff JJ revealed, "On 11/4/2024 at 1351 P-24 was evaluated by the staff JJ, WOCN (Wound Ostomy Continence Nurse) nurse. The note revealed, "Location: Coccyx, Type: DTI (deep tissue injury) open, with associated friction shear, Wound base: 25% purple, nonblanchable, 75% pink/moist, Periwound: friction shear, dry, Drainage (color/amount): scant, serous, Undermining/Tunneling: none, Photo: 11/4/24." The documentation further described, "Dressing: Triad Cream, Frequency: TID & PRN, Present on Admission: no, Hospital Acquired: yes, Recommend frequent repositioning, wedge provided for this. Prafo boot in use. Toes discolored - left open to air." Documentation continued, "Pt is ventilated, seen with RN. Ecchymosis/discolorations noted on backside.

On 11/6/2024 at 2000 P-24 care plan documentation included, "Encourage self-repositioning" although P-24 remained sedated, intubated, and on continuous renal replacement therapy (dialysis).

On 10/30/2024 at 1808 an order was placed to "Turn Patient, once stable side to side, q2h (every 2 hours)" and was marked as completed on 11/22/2024 at 0935.

On 12/11/2024 at 1215 a record review occurred of P-24's medical record and revealed under the subtitle "Position Documentation" P-24 was not repositioned on 10/31 at 1500 to 11/1 at 0800 (14 hours).

Further record review revealed the following time lapses in documentation for repositioning for P-24:

11/9/2024 0746 to 2000 (8 hours)
11/9/2024 2000 to 11/10/2024 0400 (8 hours)
11/10/2024 0400 to 1000 (6 hours)
11/10/2024 1000 to 1400 (4 hours)
11/14/2024 2200 and 11/15/2024 0000 - patient remained in same position per footnotes T705 and T706
11/18/2024 1000 to 1700 (7 hours)
11/19/2024 from 0000 to 0400 (4 hours).
11/19/2024 2000 to 11/20/2024 0514 (9 hours).
11/21/2024 0800 to 11/21/2024 1230 (4.5 hours)
11/21/2024 2000 to 11/22/2024 0800 (12 hours)
11/23/2024 0600 to 11/24/2024 2100 (41 hours)
11/24/2024 2100 to 11/25/2024 0354 (7 hours )
11/25/2024 0354 to 11/25/2024 0800 (4 hours)
11/25/2024 0800 to 11/25/2024 2000 (12 hours)
11/25/2024 2300 to 11/26/2024 0800 (9 hours)
11/26/2024 0800 to 11/26/2024 2011 (12 hours)
11/27/2024 1200 to 11/27/1800 (6 hours)
11/28/2024 0000 to 11/28/2024 0520 (5 hours)
11/28/2024 0520 to 11/28/2024 1945 (14 hours)
11/28/2024 1945 to 11/29/2024 0200 (6 hours)
11/29/2024 0200 to 11/29/2024 1500 (13 hours)
11/29/2024 1500 to 11/29/2024 2100 (6 hours)
11/29/2024 2100 to 12/1/2024 0346 (6.5 hours)
12/1/2024 0346 to 12/1/2024 2000, (16 hours)
12/2/2024 0600 to 12/2/2024 2100 (15 hours)
12/3/2024 0500 to 12/3/2024 2000 (15 hours)
12/3/2024 2100 to 12/4/2024 0300 (6 hours)
12/5/2024 0245 to 12/6/2024 0903 (6 hours)

Record review revealed the patient was not turned as recommended and as ordered.

On 12/11/2025 at 1230 during an interview with staff C, it was confirmed P-24 was not turned as ordered.

According to the policy titled, "Inpatient Skin Assessment and Intervention Guidelines," dated 3/16/2021, policy ID#15415942, under "Assessment Standards, the following is documented, "F. Major Risk Factors for Pressure Injury/Skin Breakdown:
1. Anticipated bedrest for over 24 hours
2. Vasopressor therapy
3. Sepsis or suspected sepsis
4. Mechanical ventilation
5. Compromised nutrition (low serum albumin)
6. Restraints
7. Dialysis
8. Procedures lasting 3 hours or more
9. Compromised tissue viability (severe bruising, edema, vascular deficiency, high
doses of steroids, anticoagulation)
10. History of pressure injures
11. Other risk factors per nursing judgement."

The guidelines continue with, "When risk areas are identified, select individualized interventions to meet patient skin outcome goals. The plan of care shall be based on the specific areas of risk, as well as the total risk assessment score," and "H. When risk areas are identified, select individualized interventions to meet patient skin outcome goals. The plan of care shall be based on the specific areas of risk, as well as the total risk assessment score...I. Refer to Appendix A: Braden Risk Assessment and Nursing Interventions for specific interventions that can be incorporated into the plan of care."

Review of "Appendix A: Braden Risk Assessment and Nursing Interventions," dated 6/25/2020, occurred on 12/11/2025 at 1310. Under the subtitle, "Braden Subscale: Sensory Perception...Nursing Interventions," the following is documented, "Establish turning / repositioning schedule (timing based on patient ' s needs). Minimally q2hrs (every 2 hours) while in bed and q1hr while in chair."