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Based on policy review, record review and interview, the hospital failed to ensure patients' rights were protected to receive care in a safe setting and failed to ensure all patients' were free from neglect for 1 of 3 (Patient #1) who developed an unstageable pressure injury from laying on a bedpan for an indeterminate period of time.

The findings included:

Patient #1 was admitted to the hospital on 12/1/2021 with left hip pain. Patient #1 was admitted with a prosthetic joint infection, left hip effusion and underwent a left hip arthroplasty revision on 12/3/2021. Patient #1 had multiple comorbidities during the hospital stay. Patient #1 had a negative pressure machine on his left hip surgical wound that was placed while in surgery. Patient #1 was a patient in the hospital for 27 days. Sometime during the hospital stay, Patient #1 was placed on a bedpan. It was unknown what day or how long Patient #1 was left sitting on the bedpan. Patient #1 developed two (2) unstageable pressure injuries on the left and right buttock consistent with the shape of a bedpan. Once discovered, the hospital staff did not notify a physician, did not request a wound care consult, complete an incident report or elevate the issue to management staff for 4 days after the pressure injuries were discovered. During a telephone interview with Patient #1, Patient #1 confirmed he was left on a bedpan for a "long time". Patient #1 was not sure how long he was left on the bedpan, but stated it was anywhere from 1 to 3 days.

Refer to A-0145

Based on policy review, record review and interview, the hospital failed to ensure all patients were free from neglect, failed to immediately identify the neglect, failed to protect all patients from injuries due to neglect, failed to report the injuries to administration and failed to immediately implement interventions to further prevent neglect for 1 of 3 (Patient #1) sampled patients who was neglected and found with significant pressure injuries on bilateral buttocks that was consistent with the shape of a bedpan.

The findings include:

1. Review of the hospital's policy titled, Plan for Patient Safety, Performance Improvement and Risk Management with a revised date of 1/1/2013 and a last approved date of 4/2019 revealed objectives to include "...Facilitate an environment which ...Encourages internal reporting of identified opportunities and actions taken ...To provide a safe environment ...for patients ...The Leadership Team including Department Directors are responsible for ...Educating staff on sentinel events and responding appropriately when they occur ...Assuring that staff are accountable for patient safety ...All Employees are responsible for ...Identifying and reporting unsafe conditions, incidences, adverse or unusual occurrences, with or without injuries ...Reporting ...Any happening out of the ordinary which results in a potential for or actual injury to a patient ...will be reported through completion of a variance/occurrence/incident report ...The report must be completed as soon after the occurrence as possible and must be completed during the shift that the occurrence is discovered ..."

Review of the hospital's policy titled, Assessment and Reassessment of Patients with a revised date of 5/2019 revealed, "...Purpose ...To establish criteria for the reassessment of patients ...Definitions ...Reassessment ...The process of reassessment determines whether the care, treatment and services provided are meeting the patient's needs over time ...NURSING ASSESSMENT ...The Registered Nurse (RN) is responsible for overall care of the in-patient ...Vital Signs are documented as per the Standards of Practice Guidelines for Patient Care Units ...Integumentary, using NE1 [an assessment tool that helps clinical staff assess and document wounds] can stage for Wounds ...Plan of Care ...Assessment of patient will be performed on every patient at the beginning of each shift ...and with a significant change in patient condition by a licensed nurse. Other documentation completed every shift includes interventions from the Standards of Practice Guidelines for Patient Care Units..."

Review of the hospital's policy titled, NE1 Wound Assessment Tool with a revised date of 4/2017 and a last approved date of 7/2020 revealed, "...All patients receive a head-to-toe skin inspection. The inspection is done on admission and at least once per shift. Skin and Wound digital images completed by qualified staff that has passed competencies. Patient's nurse or wound care team member takes a digital image of skin injury that is caused by pressure on admission, occurrence and at the discretion of the clinician, prior to discharge (beginning with stage 1 pressure injuries ...)"

Review of the hospital's policy titled, Standards of Practice Guidelines for Patient Care Units with a revised date of 11/2021 revealed, "...The following standards of practice are provided to patients at [Named] Medical Center who are being cared for on any of the Nursing Units. These standards ...should be documented each shift ...Activities/ADL's [Activities of Daily Living] ...Assist with or assure patient performs personal hygiene needs every shift and as needed ...SKIN INTEGRITY ...Evaluate skin condition with each shift assessment ...Any identified skin integrity problem document wound using NE1 can stage ...CONSULTS ...Initiate referral to in house specialist as indicated i.e. wound/ostomy nurse ..."

Review of the hospital's policy titled, Inpatient Skin and Wound Care Treatment Guidelines - Division Standardized Policy with a revised date of 3/2018 and last approved 6/2021 revealed, "...Medical Device Related Pressure Injury: This only describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system ...Treatment of Pressure Injuries ...When a pressure injury is found, document the suspected stage and location of the injury in the patient's skin assessment. Notification to the attending NP/MD [Nurse Practitioner/Medical Doctor] and a consult placed to Wound Care is also mandatory ...Registered Nurse ...The registered nurse plays a role in wound care of the hospitalized patient by carrying out orders ...Duties include by are not limited to the following ...Performs dressing changes including all topical dressings per MD/NP nursing order ...Assesses wounds for sign of decline at time of dressing change and notifies a member of the Wound Care Service team as needed for additional assessment..."

Review of the hospital's policy titled, Discharge Planning and Referral of Patients to Post Discharge Providers with a revised date of 3/2007 and last approved 9/2018 revealed, "...On a consistent basis and in support of the ongoing post-discharge continuum of care, the following documents are routinely faxed to the post acute care providers as appropriate ...Consults ...Assessments and evaluations including Nursing..."

2. Medical record review for Patient #1 revealed the 86 year old patient was admitted through the Emergency Department (ED) to the hospital on 12/1/2021 with a diagnosis of Left Hip Pain. Patient #1 went to surgery on 12/3/2021 for a left hip replacement revision.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/16/2021 revealed Patient #1 received a bath and linen change on 12/16/2021. There was no documentation regarding any pressure injuries discovered during this bath.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/17/2021 at 5:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Wound base visible: Yes ...Skin alteration details: DRY AND CLEAN OPEN TO AIR ...Altered level stage: Full Thickness..." This was the first documentation of skin alteration on Patient #1's buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/18/2021 at 8:10 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Wound base visible: Yes ...Any open areas: No ...Altered level/stage: Closed..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/19/2021 at 7:40 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Tissue type-worst: Dressing intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/19/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Trauma related ...Tissue type-worst: Dressing intact/device..."

None of the nurses that documented the pressure injuries as abrasions from 12/17/2021 through 12/19/2021 (3 days) documented the suspected stage of the injury in the patient's skin assessment, did not notify the attending NP/MD [Nurse Practitioner/Medical Doctor] and no consult was requested for Wound Care which was mandatory per the hospital policy titled Inpatient Skin and Wound Care Treatment Guidelines - Division Standardized Policy.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/20/2021 at 8:00 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Tissue type-worst: Red/moist/smooth/shallow ...Wound base visible: Yes ...Any open areas: Yes ...Altered level/stage: Partial Thickness ...Date of last dressing change:12/20/21 ...0745 [7:45 AM]..."

12/20/2021 was the first date a consult was written for Patient #1's bilateral buttock pressure injuries. (4 days after the date of discovery on 12/17/2021).

Review of a physician order dated 12/20/2021 revealed an order for "Consult Ulcer Stage 1&2/Ostomy ...Evaluate and treat wound ...BILATERAL BUTTOCK ..."

A Wound Ostomy Continence Nurse [WOCN] Assessment dated 12/20/2021 at 10:38 AM revealed, "...VISIT WITH PT TODAY FOR NEW CONSULT ...STATED THAT HE IS USING A SLIDE BOARD AND BSC [Bedside Commode]. NOT ABLE TO WALK YET. WAS USING BEDPAN ...L [left]/R [right] BUTTOCKS - LINEAR AREA OF DARK PURPLE SKIN WITH EPITHELIAL LOSS CONSISTANT WITH OUTLINE OF BEDPAN. AREAS OF NON BLANCHABLE TISSUE. RIGHT BUTTOCKS IS APPROX [approximately] 20 X 4 [CENTIMETERS] AND LEFT BUTTOCKS IS 10 X 2 [CENTIMETERS]. PLACED OIL GAUZE AND FOAM DRESSING IN PLACE ON BOTH SIDES. ENCOURAGED PT TO NOT USE BEDPAN. MUST BE USING BEDSIDE COMMODE. WILL PLACE ORDERS FOR CARE AND SEE ABOUT EVAL [evaluation] FROM OT [occupational therapy]/PT [physical therapy]. STAFF RN AWARE OF MY VISIT AND PLAN..." This was the first visit from a wound care nurse since the wound was discovered 4 days earlier on 12/17/2021. There was no documentation of pressure injuries by photographs nor documetation of the stage of the wounds per hospital policy.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/20/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Red/moist/bumpy/granulation ...Altered level/stage: Full Thickness..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/21/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/22/2021 at 3:49 PM revealed, "...OT: Progress Note ...Pt. NOTED TO HAVE SOILED DRESSING TO R BUTTOCK WITH Pt. REPORTS OF WOUND FROM BEING ON THE BEDPAN "24 HOURS." NURSE CALLED TO COME CHANGE DRESSINGS..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/22/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of a Burn Update Note dated 12/23/2021 revealed, "...Upon chart review, patient already been seen and treated for buttock wound by WOCN. WOCN advised to re-consult burn/wound team if wound should be escalated to need surgical intervention..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/23/2021 at 9:35 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/24/2021 at 8:30 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/25/2021 at 7:20 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/25/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Pink/red/erythema/intact ...Altered level/stage: Superficial..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/26/2021 at 8:40 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/26/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/27/2021 at 9:00 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

A WOCN assessment dated 12/27/2021 at 12:39 PM revealed, "...visit with pt today for follow up. Pt able to help turn with min assist. Staff RN in room during assessment. L & R buttocks, sacral - skin is open with slough in base of wound. Increase in drainage of right buttocks. Peri skin is WNL [Within Normal Limits]. No redness, no odor, no s/s [signs/symptoms] of infection. Will change order to [[Named medication that removes dead tissue from wounds so they can start to heal] daily to help with slough removal ..."
There was no documentation of pressure injuries by photographs not documentation of the stage of the wounds per hospital policy.

Review of a physician order dated 12/27/2021 revealed an order for "Dressing Wound Care ...Wound #1 L/R [Left/Right] BUTTOCKS - DTI, [Deep Tissue Injury] OPEN SKIN ...APPLY thick layer of [Named ointment that removes dead tissue from wounds so they can start to heal] AND LONG FOAM ON EACH SIDE TO COVER THE WOUNDS ...daily..."

Review of the CLINICAL DOCUMENTATION RECORD dated 12/27/2021 at 8:10 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Unable to determine ...Tissue type-worst: Dressing Intact/device..."

Patient #1 was discharged to a Skilled Nursing Facility on 12/28/2021.

During an interview on 3/1/2022 at approximately 5:43 PM, the complainant stated that he was put on a bedpan and it was over the weekend. He could not remember how long he was on the bedpan but he thought it was 2 or 3 days. He stated when they rolled him over to get the bedpan, "It hurt real bad. They tore my skin off because I was stuck to it." He stated it was terrible and they just forgot about me on it. He stated he did not tell anyone he was on the bedpan because "after a while I could not feel it I guess."

During an interview on 3/3/2022 at approximately 3:00 PM, the Vice President of Quality and Risk Management confirmed Patient #1 had suffered actual harm when the documentation was reviewed with this surveyor. The Vice President of Quality and Risk Management confirmed the injuries were from laying on a bedpan for an unknown period of time based on the documentation in the medical record. The Vice President of Quality and Risk Management confirmed administration had no knowledge of this incident and it was not reported through the hospital's internal reporting system. The Vice President of Quality and Risk Management stated, "I hate it that one of our patients was injured."

Based on policy review, medical record review and interview, the hospital failed to ensure nursing services used nursing assessments and reassessment that identified patient care needs to develop and implement nursing interventions to prevent pressure injuries for 2 of 3 ( Patient #2 and 3) sampled patients reviewed for pressure injuries.

The findings included:

1. Patient #2 was admitted to the hospital through the Emergency Department (ED) on 1/3/2022 with a diagnoses of postoperative infection/wound dehiscence/osteomyelitis of the right shoulder as well as an infected bone graft site on the hip. The patient underwent a two surgical procedures on the right shoulder to open and drain the infection. During the second procedure, Patient #2 had antibiotic beads and a wound vacuum-assisted closure (VAC) placed. A nutrition assessment documented the patient looked "Severly malnourished" and had "severe muscle wasting" "severe generalized fat wasting" The hospital's nursing assessments/reassessments during the hospital stay revealed patient #2 was at risk for impairment of skin integrity. There was no documentation of nursing interventions for the identified problem of skin integrity impairment on the patients plan of care.

2. Patient #3 was admitted to the hospital on 12/15/2021 with diagnoses of Acute Respiratory Failure with Hypoxia, Pneumonia and Congestive Heart Failure. The patient was discharged from the hospital on 12/29/2021. The hospital's nursing assessments/reassessments during the hospital stay documented Patient #3 was at risk for skin integrity impairment. There was no documentation of nursing interventions for the identified problem of skin integrity impairment on the patients plan of care.

Refer to A - 396.

Based on policy review, medical record review, and interview, the hospital failed to ensure each patients' nursing plan of care identified appropriate patient care needs and developed and implemented nursing interventions in response to identified nursing care needs for 2 of 3 (Patient #2 and 3) sampled patients reviewed for pressure injuries.

The findings included:

1. Review of the hospital's policy titled, Assessment and Reassessment of Patients with a revised date of 5/2019 revealed, "...The RN [Registered Nurse] reviews and prioritizes the plan of care and prioritizes the plan of care once per 12 hours and/or with significant patient condition change..."

2. Medical record review for Patient #2 revealed the 61 year old patient presented to the hospital as a transfer for orthopedic services. Patient #2 was admitted through the Emergency Department (ED) to the hospital on 1/3/2022 with a diagnoses of postoperative (postop) infection/wound dehiscence/osteomyelitis of right shoulder/humerus as well as an infected bone graft site on hip. The patient was taken to the operating room (OR) on arrival to the hospital for an Incision and Drainage (I & D) of right shoulder. He was taken back to the OR on 1/10/2022 for antibiotic beads, repeat I & D and application of wound vacuum-assisted closure (VAC). The shoulder was growing methicillin resistant streptococcus aureus (MRSA). The patient was receiving Vancomycin, Rifampin per Infectious Disease.
The admission Nutrition assessment for Patient #2 dated 1/4/2022 revealed a physical assessment, "PT LOOKS SEVERELY MALNOURISHED WITH SEVERE MUSCLE WASTING* AT THE TEMPLES, SHOULDERS, AND QUADRICEPS. MODERATE TO SEVERE GENERALIZED FAT WASTING. PROCEDURAL SITE RIGHT SHOULDER W [with]/WOUND VAC. STAGE 3 PRESSURE INJURY DOCUMENTED AT THE RIGHT HIP..." Dietary followed Patient #2 with appropriate interventions during the hospital stay.

Review of the nursing assessment/reassessments dated 1/3/2022 through 1/24/2022 revealed Patient #2 was at risk for skin integrity impairment.

Review of the Evolution Plan of Care for Patient #2 revealed no "Diagnosis/problem" for skin integrity alteration.

After the surgical procedure Patient #2 had a surgical incision as well as a wound vac placed. Due to the already altered condition of the skin from the procedure, the patient had a greater potential to have further skin impairment without the development and implementation of nursing interventions for Patient #2.

3. Medical record review for Patient #3 revealed the 80 year old patient presented to the ED with shortness of breath and admitted to the hospital on 12/15/2021 with diagnoses to include Acute Respiratory Failure (ARF) with Hypoxia, Pneumonia and Congestive Heart Failure (CHF). Patient #3 lived in a skilled nursing facility prior to this admission.

Review of the nursing assessment/reassessments dated 12/15/2021 through 12/29/2021 revealed Patient #3 was at risk for skin integrity impairment.

Review of the Evolution Plan of Care for Patient #3 revealed no "Diagnosis/problem" for skin integrity alteration.

During an interview on 3/8/2022 at approximately 10:00 AM the Vice President of Quality and Risk Management confirmed there was no documentation Patient #2 or Patient #3 was at high risk for skin alterations on the patients' Plan of Care.

Due to the patient's diagnoses and treatments associated with ARF, Hypoxia, Pneumonia and CHF, the patient has a greater potential for skin impairment without the development and implementation of nursing interventions for Patient #3.

Based on policy review, medical record review and interview, the hospital failed to ensure the medical record was complete and accurate for 1 of 3 (Patient #1) sampled patients reviewed for shift documentation of pressure injuries.

The findings included:

1. Review of the hospital's policy titled, Assessment and Reassessment of Patients with a revised date of 5/2019 revealed, "...Assessment of patient will be performed on every patient at the beginning of each shift..."

Review of the hospital's policy titled, NE1 Wound Assessment Tool with a revised date of 4/2017 and a last approved date of 7/2020 revealed, "...All patients receive a head-to-toe skin inspection. The inspection is done on admission and at least once per shift..."

Review of the hospital's policy titled, Standards of Practice Guidelines for Patient Care Units with a revised date of 11/2021 revealed, "...DOCUMENTATION ...Patient assessment should be documented on Admission, Each shift and with any change in caregiver..."

2. Medical record review for Patient #1 revealed the 86 year old patient was admitted through the Emergency Department (ED) to the hospital on 12/1/2021 with a diagnosis of Left Hip Pain. Patient #1 went to surgery on 12/3/2021 for a left hip replacement revision. Patient #1 was an in-patient for 27 days and was discharged on 12/28/2021 to a Skilled Nursing Facility. Patient #1 had 2 surgical wounds resulting from the surgery on 12/3/2021. Patient #1 was placed on a bedpan sometime before 12/17/2021. On 12/17/2021 the pressure injuries were first discovered on the buttocks and were consistent with the markings of a bedpan. There was no documentation in the record to indicate when Patient #1 was placed on a bedpan or how long Patient #1 remained on the bedpan.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/17/2021 at 5:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Wound base visible: Yes ...Skin alteration details: DRY AND CLEAN OPEN TO AIR ...Altered level stage: Full Thickness..." This was the first documentation of skin alteration on Patient #1's buttocks. There was no documentation of a wound care consult or MD notification.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/17/2021 at 8:00 PM revealed no documentation of any pressure injury to Patient #1's buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/18/2021 at 8:10 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Wound base visible: Yes ...Any open areas: No ...Altered level/stage: Closed..." There was no documentation of a wound care consult or MD notification.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/18/2021 at 8:00 PM revealed no documentation of any pressure injury to Patient #1's buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/19/2021 at 7:40 AM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Tissue type-worst: Dressing intact/device ..." There was no documentation of a wound care consult or MD notification.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/19/2021 at 8:00 PM revealed, "...Skin Alteration ...Abrasion Distal Buttock bilateral ...Related clinical factors: Trauma related ...Tissue type-worst: Dressing intact/device..." There was no documentation of a wound care consult or MD notification.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/21/2021 at 9:25 AM revealed, "...Skin Alteration/Procedure site: Present/Exists..." There was no documentation of the pressure injuries on Patient #1's bilateral buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/22/2021 at 8:05 AM revealed no documentation of any pressure injury to Patient #1's buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/23/2021 at 8:00 AM revealed no documentation of any pressure injury to Patient #1's buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/24/2021 at 8:00 AM revealed no documentation of any pressure injury to Patient #1's buttocks.

Review of the CLINICAL DOCUMENTATION RECORD dated 12/28/2021 at 8:00 AM revealed no documentation of any pressure injury to Patient #1's buttocks.

Patient #1 was discharged to a Skilled Nursing Facility on 12/28/2021.

During an interview on 3/7/2022 at approximately 1:40 PM, the Chief Nursing Officer confirmed the hospital has 2 shifts per day and each shift is 12 hours. The day shift begins at 7:00 AM and ends at 7:00 PM and the night shift begins at 7:00 PM and ends at 7:00 AM. The Chief Nursing Officer confirmed a head-to-toe skin assessment is completed with the shift assessment.

During an interview on 3/3/2022 at approximately 3:00 PM, the Vice President of Quality and Risk Management reviewed the medical record with this surveyor and confirmed the medical record for Patient #1 was inaccurate and incomplete for pressure injuries.