The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interview and document review, the facility failed to ensure adequate staff was available to provide assistance with repositioning for 1 of 1 residents (P1) reviewed for pressure ulcers.

Findings include:

P1 was admitted to the facility on [DATE], with a diagnosis of left hip fracture. P1's operative report dated 1/2/19, indicated P1 underwent surgical repair of the fractured hip.
P1's History and Physical dated 1/2/19, indicated P1 had intertrigo (superficial skin rash) to the lower abdomen and groin. No other skin concerns were documented.
P1's care plan initiated 1/2/19, directed staff to turn and reposition every two hours. On 1/6/19, the care plan was updated to include a wound ostomy continence (WOC) nurse consultation, and directions for Alevyn (a bordered foam dressing) to P1's left upper buttock purple region, change every three days and as needed (PRN). Continue to reposition every two hours.

P1 was discharged from the facility on 1/9/19. P1's Discharge Instructions directed left upper buttock deep tissue injury, bordered foam dressing, change every three days and PRN.

On 2/26/19, at 9:20 a.m. registered nurse (RN)-A was interviewed. RN-A stated She was P1's caregiver the night P1 developed the pressure ulcer, but she was unsure of the date. RN-A stated she repositioned P1 throughout the night, but was not able to find staff to help her reposition P1. RN-A stated P1 required two staff for repositioning, but the unit was short staffed that night, and she was only able to make small changes in P1's positioning due to being alone. RN-A stated she did find available staff in the morning, but could not recall who helped her. RN-A stated when they went to reposition P1 for breakfast, they noticed P1 was on a bedpan. RN-A stated she had not put P1 on the bedpan during the night, because P1 had an indwelling Foley catheter (urinary catheter). RN-A stated the evening shift had not informed her they had placed P1 on the bedpan. RN-A stated she was not able to roll P1 over to her side, so she never saw the bedpan under P1 while repositioning her that night. RN-A stated P1 had redness over her buttocks area from the bedpan. RN-A stated the WOC nurse was alerted. RN-A stated the facility often "pulls" nursing assistants scheduled to the unit to do 1:1's with patients who need close observation.

On 2/26/19, at 9:40 a.m. nursing assistant (NA)-A was interviewed. NA-A stated he provided assistance to P1 the morning after she was on the bed pan all night. NA-A stated he went to do cares on P1, and noticed she had red areas on her buttocks. NA-A stated he went and informed the nurse. NA-A stated there have been problems with sufficient staff on the night shift, and it is not uncommon all nursing assistants scheduled are "pulled" to monitor patients who require 1:1 observation and care.

On 2/26/19, at 10:05 a.m. nurse manager RN-B was interviewed. RN-B stated the facility was going to reeducate staff on that unit about skin assessments on high risk patients, but had not done that yet.

The facility Skills: Bed Pans from Mosby, dated 11/28, directed to prevent pressure areas from developing on the skin, do not leave the patient on the bedpan for longer than needed.