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Based on observation, interview and record review, the facility's nursing staff failed to monitor and evaluate the nursing care for each patient in 2 of 3 sampled patients.
Findings:

Patient #2
On 01/13/2015 at 10:00 a.m. patient # 2 was lying slightly elevated with 1 pillow on his bed, coherent with a companion at the bedside. The companion introduced herself as a mother.

Patient #3
On 01/13/2015 at 10:15 a.m. patient # 3 was lying slightly elevated with 1 pillow on his bed, coherent with a companion at the bedside. The companion introduced herself as a wife, and said " I never saw anyone turning my patient or changing his position to prevent bedsore since we came here since Saturday last week, I am the only one doing that. He developed bed sore here since when he came last year. " The Surveyor verified this to the patient, and he nodded saying " No, I was not turned since this morning. "


During an interview on 01/13/2015 at 10:25 a.m. with assigned Nurse (3) for patient # (3), the Surveyor asked the Registered Nurse for a copy of her monitoring to prevent pressure sore, and she said " I have this record. " She presented to the Surveyor that the patient was turned at 7am,9am, 12 pm, and 3pm on 01/13/2015. Record review of patient #3 revealed patient has Sacral and Heel Ulcers, with a documentation showing an advanced positioning of patient.


During an interview on 01/13/2015 at 10:30 a.m. with assigned Nurse (3) for patient # (3), the Surveyor asked the Registered Nurse for the process of repositioning the patient and she said " We are supposed to turn our patients every 2 hours or frequently to prevent bedsore. "
Record review of patient #1 revealed patient has unstageable Pressure Ulcers on the Sacrum with a documentation showing a blank positioning of patient.

The Director of Nursing (5) said " We have a Rounding Report we can show you. " She presented to the Surveyor and the patient ' s Rounding Report with turning position was empty every hour for patient #3. The Surveyor asked her how to ensure that patients are monitored regularly to prevent bed sore, and she said " That is the hard part to prove since our nurses discard this record as this is not part of the chart. We do not have in our computer system that will show a patient was turned in a particular hour to a certain position. "

The Interim Risk Manager (2) stated " The nurses have to follow the care guidelines when they chart, and turning the patient every 2 hours is part of that. So, before the end of the shift they need to check if it was done. We are following the Lippincott Procedure for our policy about Repositioning the patient. " The Surveyor notified her that the patients are not monitored to be positioned, as there was no documentation that will support that it was performed regularly.

Lippincott Procedures about Pressure Ulcer Prevention with Revision on January 09, 2015 stated on page 1 " Turn and reposition the patient every 1 to 2 hours or more frequently as required. " Page 2 stated " Document procedure. "