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Based on observations, interviews, medical record reviews, and policy review the facility failed to evaluate and provide care in accordance with skin integrity care plans and hospital policy. This affected six of ten Medical Intensive Care Unit (MICU) patient whose records were reviewed for skin integrity care plans including repositioning every two to four hours.

Findings include:

1. On 05/27/14 from 2:15 PM through 2:45 PM a tour was made of the Medical Intensive Care Unit (MICU). Air mattresses were observed on the intensive care unit beds. On 05/27/14 at 2:24 PM Staff G confirmed all beds in the hospital's three intensive care units had pressure relieving mattress.

2. On 05/28/14 at 2:30 PM the MICU census was 18 with two available beds. Observations were made documenting the position of 14 available patients. At 4:30 PM a second observation was made of the same 14 patients. The second observation found patients in the same position as two hours prior in rooms 7070, 7071, 7072, 7077, 7079, 7081, 7082, 7083, and 7084. Nine of the 14 patients observed had not been repositioned. On 05/28/14 at 4:15 PM Staff G had stated there were 11 Registered Nurses (RN) on the floor providing direct care for the 18 patients.

On 05/29/14 at 10:15 AM the MICU census was 19 with one available bed. Observations were made documenting the position of 14 available patients. At 12:45 PM a second observation was made of the same 15 patients. The second observation found patients in the same position as two hours prior in rooms 7072, 7074, 7076, 7077, 7078, 7079, 7082, and 7083. Eight out the 14 patients observed had not been repositioned.

3. On 05/27/14 at 2:40 PM the daughter of Patient #6, in room 7071, stated the staff comes in every four to five hours to turn her mother.

4. On 05/29/14 at 10:30 AM the mother of Patient #8, in room 7075, stated she had not seen the staff turn the patient in the time she had been there. Patient #8 had been admitted to MICU on 05/28/14. The mother also added Patient #8 had been an aide for 17 years and knows how a patient should be treated. At 10:32 AM Patient #8, a stroke patient, said " same pillow, same place " .

5. On 05/30/14 ten patient records from the MICU were reviewed for skin integrity care plans, skin wound assessments, skin integrity documentation, Braden Scale documentation, and repositioning documentation. Six of the 10 records were identified with the care plan; Risk of Impaired Skin Integrity, and included documentation that identified failure to reposition the patient. One of the six records identified at risk for impaired skin integrity included documentation of skin breakdown while under MICU care. On 05/29/14 the hospital identified three of the 19 patients in MICU who had documentation of skin breakdown prior to their MICU admission.

Patient #1 was admitted on 04/04/14 and transferred to MICU on 04/22/14. A care plan, Risk for Impaired Skin Integrity, was added to the patient's encounter form on 04/25/14. Interventions included turning every two hours. Patient #1 had repositioning documentation in the DOC Flow sheet including repositioning on 04/22/14 at 9:00 AM and not again until 1:45 PM (4 hours, 45 minutes). The next documentation of repositioning occurred at 8:00 PM (6 hours, 15 minutes after the last documentation). On 04/23/14 Patient #1 was repositioned at 08:00 AM and not again until 8:00 PM (12 hours). On 04/24/14 Patient #1 was repositioned at 8:00 AM and not again until 8:00 PM (12 hours). On 04/29/14 Patient #1 was repositioned at 8:00 AM and not again until 6:00 PM (10 hours). On 04/30/14 Patient #1 was repositioned at 8:00 PM and not again until 8:00 AM on 05/01/14 (12 hours). On 05/02/14 Patient #1 was repositioned at 8:00 AM and not again until 2:30 PM (6 hours, 30 minutes). On 05/03/14 at 10:54 AM a plan of care nursing note documented Patient #1 was found to have new wounds of the buttocks as a result of a morning assessment and and directed the patient would be turned every two hours and as needed to prevent further breakdown. The patient expired on 05/04/14 at 8:15 PM.

Patient #2 was admitted on 04/02/14 and transferred to the MICU on 04/09/14. A care plan, Risk for Impaired Skin Integrity, was added to the patient's encounter form on 04/09/14. On 04/15/14 the last repositioning documentation occurred at 12:00 PM and not again until 8:00 AM on 04/16/14 (20 hours). There was no documentation of skin breakdown at any time. The patient expired on 04/16/14 at 3:20 PM.

Patient #3 was admitted on 04/17/14 and transferred to the MICU on 04/18/14. A care plan, Risk for Impaired Skin Integrity, was added to the patient's encounter form on 04/17/14. On 04/18/14 repositioning documentation occurred at midnight, 12:00 AM and not again until 8:00 AM on 04/19/14 (8 hours). The patient expired on 04/19/14 at 10:02 AM.

Patient #6 was admitted on 05/24/14 and transferred to the MICU on 05/25/14. A care plan, Risk for Impaired Skin Integrity, was added to the patient's encounter form on 05/25/14. On 05/29/14 the last repositioning documentation occurred at 8:04 AM and not again until 6:00 PM (9 hours, 56 minutes). On 05/30/14 the last repositioning documentation occurred at 8:00 AM and not again until 2:22 PM. The patient remains in the MICU. There was no documentation of any skin breakdown at the time of review.

Patient #9 was admitted on 05/17/14 and transferred to the MICU on 05/19/14. A care plan, Risk for Impaired Skin Integrity, was added to the patient's encounter form on 05/17/14. On 05/19/14 the repositioning documentation noted the patient was repositioned into the same semi-fowlers position at 7:00 AM, 8:30 AM, 9:00 AM. The afternoon documentation noted the patient was repositioned into the same semi-fowlers position at 1:00 PM, 2:05 PM, 3:00 PM, and 5:00 PM. On 05/22/14 the repositioning documentation noted the patient was repositioned into the same semi-fowlers position at 4:00 PM, 5:00 PM, 6:00 PM, 8:00 PM, 9:00 PM, 10:00 PM, 11:00 PM, and 12:00 AM. On 05/29/14 the repositioning documentation noted the patient was repositioned into the same semi-fowlers position at 4:00 PM, 5:00 PM. 6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, and 10:00 PM. Documenting the patient in the same potion for hours at a time failed to follow the care plan to turn and reposition every two to four hours. The patient remains in MICU. There was no documentation of any skin breakdown at the time of review.

Patient #10 was admitted on 04/16/14 and transferred to MICU on 05/04/14. A care plan, Risk for Impaired Skin Integrity was added to the patient's encounter form on 04/23/14. On 05/04/14 the repositioning documentation noted the patient was repositioned into the same semi-fowlers potion from 11:30 AM through 6:00 AM on 05/05/14 (18 hours, 30 minutes). Documenting the patient in the same potion for hours at a time failed to follow the care plan to turn and reposition every two to four hours. The patient remains in MICU. There was no documentation of any skin breakdown at the time of review.

On 05/27/14 hospital policy #1.4.109, titled Pressure Ulcer Prediction and Treatment, was reviewed. The policy documented preventative interventions included repositioning patients at least every two to four hours, documenting the repositioning in the DOC Flow sheet under Assessment/Activity/Reposition and placing at risk patients on pressure redistribution surface/bed. The policy documented all intensive care unit beds to be pressure redistribution surfaces.

On 05/30/14 at 1:00 PM Staff J confirmed the multiple documentation identified by review of the medical records of the patients who were in the same position for more than four hours at a time without being repositioned as directed by the Risk for Impaired Skin Integrity care plan interventions and in the hospital policy Pressure Ulcer Prediction and Treatment.

Based on medical record review, staff interview, and policy review, the facility failed to ensure staff followed current facility policies for providing results of STAT labs within 30 minutes. This affected Patient #6. The hospital census was.

Findings include:

The medical record of Patient #6 was reviewed and revealed admission documentation the patient was admitted to the hospital from a long term care facility with reports of difficulty breathing and increasing malaise on 05/24/14 at 09:17 PM. A STAT order for a Basic Metabolic Panel (BMP) was placed by a physician at 09:26 PM. The Laboratory received the order at 09:30 PM and the blood sample was collected at 09:33 PM. The final results of the blood test were not available until 11:38 PM, more than two hours after the Laboratory collected the blood sample. The BMP results noted a critically high blood urea nitrogen (BUN) level of 112 mg/dL (a normal BUN is 7-25 mg/dL). The critical lab value was reported to a staff nurse at 11:38 PM as required by facility policy.

The facility policy entitled Department Goals and Scope of Services was reviewed. According to the policy the expected turn around time for STAT testing is 30 minutes after receipt. The facility policy entitled Expected Delays in Testing was reviewed. According to this policy when unexpected circumstances in the laboratory interfere with the ability to complete testing within a reasonable timeframe, healthcare providers must be notified of the delay and the expected time of results availability. The policy further stated expected reporting times in "worst case scenarios" should not exceed 90 minutes for STAT samples.

Staff E was interviewed on 05/30/14 at 11:45 AM. After reviewing the results on the computer, Staff E confirmed these lab results were reported well after the 30 minute turn around time. It was also confirmed that the final results exceeded even the worst case scenario turn around time. Staff E stated: "I'm not sure where the delay was."