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Based on policy review, observation, medical records review and staff interviews the facility staff failed to obtain a physician order for non-violent restraint in 7 of 16 patients with restraints (patient #7, 10, 11, 12, 13, 14 and 16).

The findings include:

Review on 03/21/2017 of the policy and procedure "Restraints, Management of Patient in" (approved date 02/10/2016) revealed, "... A.7. Side rails are not a restraint if they must be raised for the bed to be operational, or if they are used to meet the following assessment patient needs: a. patient request b. Sedated, comatose ..."

Observation on 03/21/2017 at 1330 during tour on the 4th floor revealed patients lying in their beds with all 4 side rails up in room 449, 439, 440, 435 and 446. Observation on 03/22/2017 at 0900 during tour on the 5th floor revealed patients lying in their beds with 4 side rails up in room 520 and 510.

1. Review of open medical record on 03/22/2017 revealed patient #7 was assigned to room 449. Patient #7 was admitted on 03/14/2017 with fever and dehydration. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/21/2017 at 1310 with RN #1 revealed the use of restraints required a physician order. Interview revealed the use of 4 side rails was considered a restraint unless specific conditions are met as per policy.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

2. Review of open medical record on 03/22/2017 revealed patient #10 was assigned to room 439. Patient #10 was admitted on 03/13/2017 with hypertension. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

3. Review of open medical record on 03/22/2017 revealed patient #11 was assigned to room 440. Patient #11 was admitted on 03/20/2017 with unresponsive in rehabilitation. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

4. Review of open medical record on 03/22/2017 revealed patient #12 was assigned to room 435. Patient #12 was admitted on 03/19/2017 with shortness of breath and hypoxemia. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

5. Review of open medical record on 03/22/2017 revealed patient #13 was assigned to room 446. Patient #13 was admitted on 03/08/2017 with shortness of breath. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

6. Review of open medical record on 03/22/2017 revealed patient #14 was assigned to room 520. Patient #14 was admitted on 03/19/2017 with left hip pain. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/22/2017 at 0925 with LPN #1 revealed 4 side rails were used for falls precaution. Interview revealed 4 side rails were no longer considered restraints.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

7. Review of open medical record on 03/22/2017 revealed patient #16 was assigned to room 510. Patient #16 was admitted on 03/17/2017 with abdominal pain, vomiting and diarrhea. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/22/2017 at 0910 with patient #16 revealed patient #16 did not request for 4 side rails to be up. Interview revealed 4 side rails were up because patient #16 was on falls precautions.

Interview on 03/22/2017 at 0930 with RN #2 revealed the use of 4 side rails without the patient's request or indicated need was considered restraints per facility policy. Interview revealed the company providing the beds indicated the use of 4 side rails was not considered restraints due to gap at the bottom of the bed where patient can get out.

Interview on 03/22/2017 at 0950 with AS #3 revealed review of the restraints policy with night staff on 03/21/2017. Interview revealed the staff's understanding of the use of 4 side rails was inconsistent. Interview revealed the restraints policy was the source of confusion. Interview revealed all staff will be immediately retrained on the use of 4 side rails as a restraint.

Based on policy and procedure review, "STEPWISE APPROACH TO EARLY MOBILITY" protocol review, Nursing Leadership meeting minutes review, medical record reviews, patient and staff interviews, the hospital nursing staff failed to supervise the nursing care of a patient by failing to respond to a change in a patient's condition to prevent progression of skin breakdown for 2 of 4 patients (#1 and #9) with a Braden Score less than 18 (score used to predict pressure sore risk, 18 or less is high risk).

The findings include:

Review on 03/21/2017 of the "ASSESSMENT FOR SKIN INTEGRITY" policy, revised 06/2015, revealed, "I. POLICY The nursing staff will implement the Pressure Ulcer Prevention and Treatment Guidelines based upon their assessment of skin...The nursing staff will developed a plan of care based upon these prevention and treatment guidelines and alter the plan of care based upon changes in the patient status....B. Determine the Braden Scale for predicting pressure ulcer risk...1. Patients with a Braden Score of 18 or less are at high risk for developing a pressure ulcer and other breakdown. Prevention measures will be implemented using the (Hospital) Pressure Ulcer Prevention Practices and Treatment Guidelines...E. Notify the physician or appropriate care provider of any notable changes in condition...."

Review on 03/21/2017 of the "(Hospital) PRESSURE ULCER PREVNTION PRACTICES AND GUIDELINES", no date, revealed, "Treatment Parameters For Pressure Ulcers...If ANY stage pressure ulcer...develops: -Provide pressure relief/reduction to the affected area...Stage II Pressure Ulcer: - Measure ... - For moderately draining..., apply foam dressing and change every 3 days and PRN drainage - Consider... Physical Therapy evaluation/consult [sic] for immobility issues. - Consult WOC (wound/ostomy care) nurse if ulcer deteriorates or does not improves [sic] within 5-7 days...."

Review on 03/21/2017 of the "ASSESSMENT OF PATIENTS", revised 11/2015, revealed, "...E. Scope of Responsibility 1. Nursing ... c. Patients will have ongoing assessments..., with changes in patient condition and/or diagnosis, and to determine the patient's response to intervention....Ongoing assessments of a patient will reflect...pertinent changes, and response to intervention. More frequent assessments will be completed as appropriate for the...individual patient need.

Review on 03/21/2017 of the ICU's (Intensive Care Unit) "STEPWISE APPROACH TO EARLY MOBILITY" protocol revealed a four (4) step process used to identify steps implemented in the progression of recovery and mobilization. "STEP 1 Goal: Clinical stability and orthostatic conditioning (patient unable to ambulate or get out-of-bed]) -Turn Q (every) 2 hours -HOB > 30° (Head of Bed greater than or equal to 30 degrees) at all times -PROM (passive range of motion) Q 8 hours -Bed in chair position for 20 min (minutes) TID (3 times daily) as tolerated".

Review on 03/22/2017 of the Nursing Leadership meeting minutes dated 08/25/2016 revealed a topic titled, "Pressure Ulcer Prevention Team" was presented from the Education Council. The council proposed that the hospital follow the fall precaution process to standardize care. Review revealed "More to come" was documented out from the proposal. Continued review of the minutes through March 2017 revealed no additional documentation of the proposal.

1. Closed medical record review on 03/21/2017 for Patient #1 revealed a 58 year old presented to the emergency department (ED) on 02/10/2017 with complaints of worsening generalized abdominal pain. Review of the "ED Physician Documentation" by Medical Doctor (MD) #1 on 02/10/2017 at 1357 revealed, "... has been suffering from ulcerative colitis, frequent bouts of abdominal pain and tenderness, as well as multiple hospitalizations....colonoscopy was this month showing multiple areas of ulceration of her colon concerning for ulcerative colitis....On exam, she has peritonitis (inflamed abdominal lining)...." Continued review revealed, "...Impression and Plan Diagnosis Acute peritonitis ...Septic shock.... Condition: Critical Disposition: Admit to surgery...." Review of the History and Physical (H&P) by MD #2 dated 02/10/2017 at 1438 revealed, "...Impression and Plan Diagnosis Perforated Viscus....with hx (history) of pan-colitis (involving the entire colon). Will proceed with emergency abdominal exploration with possible bowel resection and possible ostomy....." Review revealed an ostomy was required and the patient was transferred to the ICU, intubated, post-operatively. Review of the of the nursing care flowsheet 02/11/2017 - 03/01/2017 revealed the patient required "Maximum assistance" with personal/hygiene care, "two person assist" with activities and was on "bedrest". Nursing documentation varied from independent to two person moderate assist with repositioning/turning throughout hospitalization. Continued review of the "Integumentary" nursing care flowsheets 02/10/2017 to 03/01/2017 revealed Braden Scores of:

- 02/10/2017 at 2000: 15 (no sensory perception impairment, bedfast, very limited mobility, probably inadequate nutrition, and potential problem with friction and shear). Review revealed the patient was a high risk for development of pressure sores per the hospital's "ASSESSMENT FOR SKIN INTEGRITY" policy.
- 02/11/2017 at 0700: 14 (slightly limited sensory perception impairment, bedfast, very limited mobility, probably inadequate nutrition, and potential problem with friction and shear). Review revealed a change from no sensory impairment to slightly limited). Review revealed a one (1) point decrease in the Braden Score, no documentation of physician notification, patient's response to treatment, or wound consult. Continued review revealed Registered Nurse (RN) #1 noted an open "skin tear" (#1) located midline of the buttock, "Open to air".
- 02/12/2017 at 0700: 13 (no change from assessment above). Review revealed a two (2) point decrease from baseline. Review revealed no documentation of physician notification or patient's response to treatment.
- 02/13/2017 at 2000: 15 (no sensory perception impairment, bedfast, very limited mobility, probably inadequate nutrition and potential problem with friction and shear). Review revealed a two (2) point increase in the Braden Score. Review revealed a change from slightly limited to no sensory impairment).
- 02/14/2017: No change in Braden Score or assessment.
- 02/15/2017 at 0700: RN #2 noted a "Skin tear" (#2) on the left lateral hip. Review revealed a foam dressing was applied at 1900 by RN #4. Continued review revealed no documentation of physician notification or patient's response to treatment.
- 02/15/2017 at 1500: 15 (slightly limited sensory perception impairment, chairfast, slightly limited mobility, adequate nutrition and potential problem with friction and shear). Review revealed a change from no sensory impairment to slightly limited impairment).
- 02/16/2016 at 0700: 17 (no sensory perception impairment, chairfast, slightly limited mobility, adequate nutrition and potential problem with friction and shear.) Review revealed a two (2) point increase in the Braden Score.
- 02/16/2017 at 1900: 15 (slightly impaired sensory perception, chairfast, slightly limited nutrition and potential problem with friction and shear). Review revealed no sensory perception impairment to slightly impaired.
- 02/17/2017 at 0800 - 02/18/2017 at 1600: No change in Braden Score or nursing assessment. Continued review revealed no further documentation of ongoing assessment of the patient's Braden Score, sensory perception, activity, mobility, nutrition, or friction and shear status.
- 02/18/2017 at 0500: RN #5 noted a "Skin tear" on the "Left Inferior Buttock" (#3) and "Right Inferior Buttock" (#4). Review revealed no documentation of physician notification, how the skin tears occurred, or wound consultation.
- 02/19/2017: Five (5) total wounds identified. One (1) surgical wound and four (4) "Skin tear" wounds. Review revealed no documentation of physician notification of the patient's steady decline or wound consult regarding the progression of skin breakdown. Review revealed no documentation of the patient's response to treatment
- 02/21/2017 at 0130: Transferred to the Medical/Surgical Unit. Review revealed documentation of a "Pressure Reducing Device" and "Pressure Reducing Sleep Surface" intervention 02/21/2017 at 0740, 02/23/2017 at 2016 (~2 days, 11 hours, 36 minutes later) and 03/01/2017 at 0759 (~5 days, 11 hours, 45 minutes later). Review revealed no documentation of the use alternative pressure reducing devices or measures for (~ 8 days).
- 02/21/2017 at 1535: RN #7 noted "skin breakdown" on the hip, midline buttocks, right and left inferior buttocks and the foam dressings were changed following the wound assessment. There were no documented measurements of the area as outlined in the "(Hospital) PRESSURE ULCER PREVNTION PRACTICES AND GUIDELINES".
- 02/21/2017 at 1955: RN #8 documented the "midline buttock" wound as a "pressure ulcer". There were no documented measurements of the wound as outlined in the hospital policy guidelines or MD notification of the patient's change in condition or response to treatment.
- 02/26/2017 at 1950: RN #8 noted "Visible adipose" as the wound bed description when the foam dressing was removed. Review revealed no documentation of physician notification, wound consult, or patient's response to treatment.
- 02/27/2017 at 1449: RN #9 requested and received a wound consult order (12 days from skin tear #5 on 02/15/2017 and 6 days from the development of pressure ulcer on 02/21/2017)
- 02/28/2017 at 1355: Wound/Ostomy Care Nurse (WOC) consultative findings revealed, Stage II pressure ulcers on the sacrum, right buttock and left buttock were identified. Additionally, a "skin tear" on the left abdominal fold was discovered during the assessment. The wounds were measured, cleansed with sterile saline, a non-alcohol skin barrier film and a Mediplex foam dressing was applied outlined in the "(Hospital) PRESSURE ULCER PREVNTION PRACTICES AND GUIDELINES". Planned follow up assessments was "2x/Wk TuF (daily on Tue and Fri)". Review revealed no documentation of physician notification of patient's change in condition or response to treatment.
- 02/29/2017 at 1927: RN #8 noted a "Pressure ulcer" on the right inner thigh (#5) and "open pressure area" on the "Perineum" (#6). Review revealed no documentation of physician notification of two new pressure areas, pressure reducing devices or surfaces, patient's response to treatment.

Review on 03/21/2017 of the Discharge Summary by MD #3 on 03/01/2017 at 1521 revealed the patient was discharged to an inpatient rehabilitation facility. Review revealed documentation for care of and instructions for the abdominal, surgical wound but there was no documentation regarding the skin tears or Stage II pressure ulcer.

Interview during unit tour on 03/21/2017 at 0940 - 1115 with the Nurse Manager revealed she recalled having a patient on the Medical/Surgical unit "a couple weeks ago who came in with a sore from home, got some skin tears and progressively got worse." Interview revealed the patient underwent surgical intervention for ulcerative colitis on 02/10/2017, was admitted to the ICU and was transferred to the Medical/Surgical unit on 02/21/2017 at 0130. Interview revealed the patient's skin impairment progressively worsened over the course of hospitalization.

Interview on 03/21/2017 at 1545 with the Wound Care Team (WCT) Manager revealed when a patient comes in with a Stage I skin impairment, "unless it is open, we usually do not do a consult (wound). We focus on treatment as opposed to prevention." Continued interview revealed that based on the Braden Score, "prevention measures are implemented. A Braden Score of 15 triggers preventive interventions, turning every two (2) and barriers creams. The WOC nurse is consulted when there's a change in condition." Further interview revealed all skin tears and the stage II pressure ulcer was considered, "hospital acquired" and counted as such in their Quality Assurance/Performance Improvement (QAPI) committee.

Interview on 03/22/2017 at 0820 with RN #8 revealed she was the nurse assigned to Patient #1's care on 02/21/2017 during the 7p-7a shift. Interview revealed during rounds, I would see her move from side-to-side. She could move in bed but could not get up independently and lift or shift her bottom." Interview revealed, "Sometimes she needed help getting all the way up on one side or the other." Continued interview revealed following RN #8's assessment and concern regarding the number of skin break down on the patient, she "noticed there was no wound consult and requested one during hand off to the ongoing shift 02/21/2017 at 0700. Interview revealed she did not care for the patient again prior to discharge and did not know whether the consult was ordered or not."

Interview on 03/22/2017 at 0855 with the WOC nurse revealed she initially evaluated the patient in ICU on 02/10/2017 following a consultation for ostomy care. "I talked to the nurse and she told me she (patient) had skin tears." Interview revealed the WOC nurse did not assess the skin tears at that time because she was consulted for ostomy care. "We usually don't do consults for skin tears. Looking back now, maybe I should have looked at them but she (nurse) told me she had just dressed them all and I didn't consider it at the time."
Continued interview revealed the WOC nurse received a wound consultation on 02/27/2017 at 1054 from RN #9 and evaluated the patient on 02/28/2017 at 1333. During her assessment, the WOC nurse also identified another skin tear under the patient's abdominal fold. Interview revealed all skin tears and stage II pressure ulcer were considered, "hospital acquired". Interview revealed foam dressings were not transparent and visualization of the wound was not possible unless the dressing was removed and the site assessed. Interview revealed the patient demonstrated progressive decline without physician notification or aggressive treatment intervention.

Interview on 03/22/2017 at 1000 with the Vice President Nurse Executive (VPNE) revealed, "We need to look at this. We've got a problem and we need to fix it, it's as simple as that." Interview revealed the VPNE's expectation for nursing staff is that preventive measures are to be implemented and documented. She indicated that the expectation is also that the physician is notified with any change in the patient's condition. "We own this. We're going to look at that policy, do some education and to get the ball rolling before a patient's condition progressively worsens."

Interview on 03/22/2017 at 1035 with RN #9 revealed she was the nurse who initiated the wound consultation on 02/27/2016. Interview revealed the patient had a "Stage II sore on her coccyx and the others were skin tears (right and left buttocks, left lateral hip)." Continued interview revealed that one 02/27/2017 (day wound consult was ordered) RN #9 changed the dressing on the patient's coccyx and noted that the patient was excoriated in the groin area" and noted a "blister on the left side. That's when I looked to see if the WOC team was following her." Interview revealed there had not been a wound consult and RN #9 entered one."

Interview on 03/22/2017 at 1310 with the Chief Medical Director revealed physicians should be aware of the patient's condition. "The surgery team works closely with administrative staff to develop protocols with the Wound Care Team (WCT). They are comfortable with the protocol of wound care and are confident in the nursing criteria used to evaluate wounds." Continued interview revealed, "Documentation is available and viewable to physicians, I can't say they always look at that, but it is available. Going forward, we're going to work on communication. This is a key opportunity to improve our process."

Interview on 03/22/2017 at 1355 with MD #3 he revealed he sees the patient in his office and followed her during her hospitalization post-operatively. Interview revealed he was the discharging physician on 03/01/2017, "I was not aware of this (the patient's skin integrity impairment) until this morning. I would've documented and would've gotten the WCT involved much earlier in her stay." Interview revealed MD #3 was not notified of the patient's change in condition.

Interview on 03/22/2017 at 1630 with the WCT Manager revealed proposal of a standardized process for pressure ulcer prevention was discussed in the August 2016 Nursing Leadership meeting and "kinda fell by the wayside." Interview revealed the proposal will be revisited following the survey.

2. Medical record review on 03/22/2017 for Patient #9 revealed a 56 year old presented to the ED on 03/07/2017. Review of the History and Physical (H&P) by MD #4 on 03/07/2017 at 2055 revealed he was hospitalized from 02/22/017 until 03/02/2017 for a left colectomy (removal of the left colon with reattachment) for ischemic colitis (poor blood supply to the colon) on 02/22/2017. Upon presentation to the ED the he reported that he "developed progressive abdominal distention ...Today he began having spontaneous drainage of foul-smelling, straw-colored fluid from his midline abdominal incision." Continued review revealed, "IMPRESSION: 1. Abdominal wound infection and cellulitis ...9. Peripheral arterial disease ..." He was admitted to the Medical/Surgical unit. Continued review of the nursing care flowsheets 03/07/2017 to current revealed Braden Scores of:

- 03/07/2017 at 2125: 22 (no sensory impairment, walks occasionally, minimal assist, no limitations with mobility, no apparent problem with fiction and shear and excellent appetite)
- 03/08/2017 at 0745: 21 (no change from above). Review revealed a 1 point drop from baseline.
- 03/08/2017 at 1940: 20 (no sensory impairment, walks frequently, moderate assist, slightly limited mobility, adequate nutrition, no apparent problem with friction). Review revealed a 2 point drop from baseline and a change from minimal assist to moderate and no limitations with activity to slightly limited.
- 03/09/2017 at 0720: 17 (maximum assist). Review revealed a 5 point drop from baseline with no documented change in treatment or physician notification of patient's change in condition.
- 03/09/2017 at 2000: 16 (very limited sensory perception, bedfast, adequate nutrition, no limitations with activity, and adequate mobility). Review revealed a 6 point drop with no documented change in treatment or physician notification of patient's change in condition.
- 03/10/2017 at 0800: 16 (no sensory impairment perception, chairfast, very limited mobility, nutrition probably inadequate, and potential problems with friction and shear). Review revealed a change from adequate nutrition to probably inadequate and potential problems with friction and shear. Review revealed no documented change in treatment or physician notification of patient's change in condition.
- 03/10/2017 at 2015: 13 (very limited sensory impairment, bedfast, very limited mobility, nutrition probably inadequate, and potential problem with friction and shear). Review revealed a 9 point drop from baseline with no documented change in treatment or physician notification of patient's change in condition.
- 03/11/2017 at 1900: "Excoriation, erythema" and swelling noted to the "midline sacrum". No documented change in treatment or physician notification of patient's change in condition.
- 03/12/2017 at 0915: Pressure ulcer, stage II noted to the "Right Inner Buttock" and "Left Inner Buttock, deteriorating", not present on admission, in addition to the "Midline Sacrum" wound. No documentation of physician notification of patient's change in condition.
Review revealed a steady decline in the patient's condition with no documented change in treatment, implementation of pressure prevention interventions, or physician notification.

Interview on 03/22/2017 at 1000 with the Vice President Nurse Executive (VPNE) revealed, "We need to look at this. We've got a problem and we need to fix it, it's as simple as that." Interview revealed the VPNE's expectation for nursing staff is that preventive measures are to be implemented and documented. She indicated that the expectation is also that the physician is notified with any change in the patient's condition. "We own this. We're going to look at that policy, do some education and to get the ball rolling before a patient's condition progressively worsens."

Interview on 03/22/2017 at 1630 with the WCT Manager revealed proposal of a standardized process for pressure ulcer prevention was discussed in the August 2016 Nursing Leadership meeting and "kinda fell by the wayside." Interview revealed the proposal will be revisited following the survey.

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