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Based on record review and interview, the facility failed to ensure the 10 of 10 patient's (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) right to care in a safe setting, in that,

Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 each developed a hospital acquired pressure injury during their respective admissions.

Findings included

Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 developed a hospital acquired pressure injury during their respective admissions.

During an interview on 12/11/18 ending at 3:50 PM with Personnel #3, Personnel #1 was present. Personnel #3 confirmed the HAPI's occurred and discussed the circumstances surrounding each of the Pressure Injury (HAPI) patients.

The 8/03/17 "Patient Rights and Responsibilities" policy required, "right to care that is considerate and respectful...care in a safe setting..."

The 10/12/17 last reviewed, "Skin Breakdown Prevention, Pressure Injury, Skin Tear, and Incontinence Skin Care Management" policy required, "to prevent hospital acquire pressure injury..."

Based on record review and interview, the facility failed to ensure the RN (registered nurse) evaluated the nursing care for each patient, in that,

Patient #1 was discharge with 2 hospital acquired pressure injuries that were not discovered upon assessment prior to discharge to the rehabilitation facility.

Findings included

The rehabilitation facility's admission record for Patient #1 on 9/19/18 reflected 2 pressure injuries (Left heel redness, sacral/coccyx stage II) by the nurse, wound care and physician. Color pictures dated 9/19/18 were present and viewed.

The acute facility record did not reflect the same 2 pressure injuries at discharge/transfer on 9/19/18 for Patient #1.

During an interview on 12/11/18 ending at 10:48 AM, Personnel #10 (rehabilitation facility) discussed the wounds Patient #1 arrived with - coccyx and Left Heel that were not on his medical record or in the nurse to nurse report."

During an interview on 12/12/18 ending at 10:19 AM, Personnel #1 and #2 discussed the Left ear pressure injury. They were asked about the Left heel redness, sacral/coccyx stage II. Personnel #2 stated, "No. The skin assessment prior to discharge did not document anything other than the ear."

The 10/12/17 last reviewed, "Skin Breakdown Prevention, Pressure Injury, Skin Tear, and Incontinence Skin Care Management" policy required, "to prevent hospital acquire pressure injury..."