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Based on record review and interview, nursing staff failed to follow facility policy/guidelines and acceptable standards of practice regarding turning and repositioning of 1 (#9) of 2 patients reviewed for pressure injury wound care resulting in the potential for worsening wounds and poor patient outcomes. Findings include:

On 3/12/2024 at 1404, review of the medical record for P-9 revealed he was a 78-year-old male who was admitted to MICU (medical intensive care unit) on 7/27/2023 for continuous EEG (electroencephalogram-test to measure the electrical activity of the brain). Past medical history included a meningioma (a usually noncancerous tumor that arises from the membranes surrounding the brain and spinal cord), seizures, chronic kidney disease Stage V, Type II diabetes, hypertension (high blood pressure), and hyperlipidemia (high fat content in the blood). P-9 remained in MICU until 7/31/2023 when he was transferred to a stepdown unit. He remained on stepdown until 10/15/2023 with a slow overall decline of health. Palliative care was consulted and recommended hospice; however, the family chose to continue with aggressive treatment. He was moved back to MICU on 10/15/2023 and was there until 10/25/2023 when he transferred to a long-term acute care hospital (LTACH).

Physician notes dated 7/27/2023 revealed P-9 was "obtunded (state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) and unresponsive on arrival." GCS (Glasgow Coma Scale - a clinical scale used to reliably measure a person ' s level of consciousness after a brain injury by measuring eye opening, verbal responses, and motor responses. Scoring 13-15: mild; 9-12: moderate; 3-8: severe; and <3: vegetative state) score was 6 with response to pain. A 24-hour continuous EEG was consistent with a "mild to moderate degree of diffuse encephalopathy..." P-9 had wounds noted to be in the coccyx area on admission.

The initial nursing assessment dated 7/27/2023 revealed Braden score (assessment tool used to document patient risk for developing pressure injuries-very high risk <10, high risk 10-12, moderate risk 13-14, mild risk 15-18) was 10. Review of the Braden scores revealed his scores remained between 9-13 throughout the entire hospitalization.

On 7/28/2023 at 0339, the physician ordered a wound consult "for multiple possible stage 2 wounds on coccyx." The consult occurred later that same day at 1226. It described a 10 cm (centimeter) x 10 cm area over the coccyx. The consult stated. "He has a large evolving DTI (deep tissue injury) on his buttocks to open pink wounds scant to no drainage... A plan of care was discussed with the nurse." The plan of care included a specialized bed, turning/repositioning the patient every two hours, floating the heels, frequent position changes, daily cleansing of the area with cleansers and wipes, and use of a lotion.

When interviewed on 3/12/2024 at 1615, Wound Care Nurse Staff EE stated when she saw the wound on 7/28/2023, it was "an evolving deep tissue injury" which "always evolves into an open wound. Once it starts, there is no turning it around when it is that extensive. It just keeps getting worse and worse." Staff EE stated the recommended treatment was the standard treatment per facility guidelines.

Further review of the medical record revealed there were multiple gaps of 4+ hours between repositioning interventions throughout P-9's hospitalization. Some of the larger gaps were as follows:

-7/27/2023 from 0704 to 7/28/2023 at 0052 (17 hours, 48 minutes). It was 12 hours and 27 minutes from the time of the wound consult.
-8/2/2023 from 1816 to 8/3/2023 at 0057 (6 hours, 41 minutes)
-8/10/2023 from 1836 to 8/11/2023 at 0246 (8 hours, 10 minutes)
-8/14/2023 from 2201 to 8/15/2023 at 0802 (10 hours, 1 minute)
-8/17/2023 from 2052 to 8/18/2023 at 0814 (11 hours, 22 minutes)
-8/18/2023 from 0814 to 8/18/2023 at 1830 (10 hours, 16 minutes)
-8/18/2023 from 1830 to 8/19/2023 at 0224 (7 hours, 54 minutes)
-8/20/2023 from 0805 to 8/21/2023 at 0108 (17 hours, 3 minutes)
-8/21/2023 from 0108 to 8/21/2023 at 2051 (19 hours, 43 minutes)
-8/23/2023 from 1850 to 8/24/2023 at 1058 (16 hours, 8 minutes)
-9/3/2023 from 2221 to 9/5/2023 at 0015 (25 hours, 54 minutes)
-9/6/2023 from 2214 to 9/7/2023 at 1020 (12 hours, 6 minutes)
-9/14/2023 from 1453 to 9/15/2023 at 0107 (10 hours 14 minutes)
-9/16/2023 from 1704 to 9/17/2023 at 0038 (7 hours, 34 minutes)
-9/17/2023 from 0621 to 9/17/2023 at 2306 (16 hours, 15 minutes)
-9/18/2023 from 0700 to 9/18/2023 at 1854 (11 hours, 54 minutes)
-9/23/2023 from 0633 to 9/24/2023 at 0109 (18 hours, 36 minutes)
-9/24/2023 from 0633 to 9/25/2023 at 0819 (25 hours, 46 minutes)
-10/1/2023 from 1844 to 10/2/2023 at 0910 (14 hours, 26 minutes)
-10/4/2023 from 1659 to 10/5/2023 at 0143 (9 hours, 42 minutes)
-10/5/2023 from 2215 to 10/6/2023 at 1446 (16 hours, 31 minutes)
-10/6/2023 from 1446 to 10/7/2023 at 2308 (32 hours, 22 minutes)
-10/9/2023 from 2249 to 10/10/2023 at 1429 (15 hours, 40 minutes)
-10/27/2023 from 2220 to 10/28/2023 at 1058 (12 hours, 38 minutes)

During the record review on 3/12/2024 at 1430, Staff B acknowledged there were large gaps of time in which repositioning was not done or was not documented.

Review of facility guidelines titled "Skin Assessment Bundle" effective July 2021 revealed based on P-9's assessment, he should have received the following interventions: reposition every hour while sitting up; turn every 2 hours while resting in bed; off-load/elevate heels; place pillows between the knees and bony prominences to avoid direct contact; and avoid positioning individuals directly onto medical devices such as drainage tubes.

Staff B stated on 3/13/2024 at 0925 the "Skin Assessment Bundle" was available for all staff to access and could be implemented without physician order.