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Based on interview, medical records (MR's) and Policy reviews, the hospital staff failed to complete and document interventions according to interventions listed on the care plan for 1 of 10 (Pt. #1) medical records reviewed. This deficient practice had the potential to affect all 15 inpatients receiving treatment in the ICU (intensive Care Unit) at this facility.

Findings include:

On 10/30/2013 at 4:00 p.m. a review of the Policy titled Assessment/Reassessment of Patients, An Interdisciplinary Approach dated 11/2008 was completed. The policy stated in part, B. Reassessment 1. Inpatient a. The reassessment is designated to evaluate the patient's response to care and interventions and to determine if a change in the plan of care is warranted. c. The RN will modify the plan of care based on patient response and evaluation of effectiveness of interventions.

On 10/30/13 at 4:00 p.m. a review of the Policy titled Care of the mechanically ventilated patient, (undated) was completed. The policy stated in part, under interventions: 6. Maintain skin integrity: Reposition patient every two hours.

Review of pt. #1's MR on 10/30/13 beginning at 12:50 p.m. through 3:00 p.m. was completed. Pt. #1 was admitted to facility on 5/25/13 and was placed on a ventilator on 5/31/13 and remained on a ventilator until 7/3/13, when pt. #1 was transferred to a long term acute care hospital. Actual impaired skin integrity problem including a goal and interventions including repositioning patient every 2 hours was not added to the Interdisciplinary plan of care (IPOC) until 6/10/13.

Per review of pt. #1's nursing assessment flowsheet (NAF) on 10/30/13 at 2:00 p.m. was completed. NAF dated 5/25/13 pt. #1 was admitted with a skin assessment which included bilateral leg tenderness, swollen, dry and skin flaky. NAF dated 7/2/13, pt. #1 assessment stated the following: Right ear- dry scabbed. Right elbow- skin tear, fragile, scabbed. Groin- bilateral abraided, dry, edematous, flaky, peeling. Bilateral buttocks- skin tear, wound bed pink, excoriated, flaky, fragile, peeling. Coccyx dressing intact- flaky, fragile, peeling. Right foot- callus, pressure ulcer unstageable, purple, brown, dry, peeling, scabbed. Left Foot- callus, cracked, ecchymotic.

Per review of pt. #1's NAF on 10/30/13 at 2:00 p.m. was completed. NAF dated 6/1/13 indicated pt. #1 was repositioned at 12:00 p.m., 4:00 p.m., and 10:00 p.m. NAF dated 6/3/13 indicated pt.# 1 was repositioned at 2:30 a.m., 5:00 a.m., 8:30 a.m., 10:27 a.m. 12:33 p.m., 4:20 p.m., 8:35 p.m., and 12:00 a.m. NAF dated 6/4/13 indicated the next change of position (c.o.p) occurred at 4:00 a.m. NAF dated 6/4/13 indicated a c.o.p at 5:55 a.m., 8:00 a.m., 11:30 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:32 p.m., with the next c.o.p on 6/5/13 at 12:13 a.m. NAF dated 6/18/13 indicated a c.o.p at 5:45 a.m., 8:00 a.m., 12:01 p.m., and then 7:00 p.m. NAF dated 6/20/13 indicated a c.o.p at 3:31 a.m., 5:10 a.m., 9:30 a.m., 12:45 p.m., 3:45 p.m., 8:00 p.m. and at 11:24 p.m. NAF dated 6/21/13 indicated c.o.p at 11:54 p.m. and on 6/22/13 the next c.o.p is documented at 9:07 a.m., 12:12 p.m., 4:43 p.m., 8:00 p.m. and on 6/23/12 at 12:00 a.m.

Above findings confirmed with Dir. of Risk Management B at time of MR review.

Per interview on 10/31/13 at 1:00 p.m. with Dir. of Risk Management B indicated that staff is expected to provide assistance with change of position every 2 hours and to document actions on the nursing assessment flowsheet. Dir. of Risk Management B is unable to explain why the documentation is not completed.