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Based on document review, and interview the facility failed to follow the policy and procedure related to ensuring the POA family member was notified of an unanticipated outcome for one (1) of ten (10) MR's reviewed. (Patient # 7)

Findings include:

1. Facility policy titled, "Patient Rights and Responsibilities", original date 09/1991, policy number H-PC 09-001, indicated "rights and responsibilities referred to in this policy shall be protected and exercised for each patient and his/her family/guardian" at H # 1. The list of "Patient Rights and Responsibilities is provided to each patient at admission as part of the admission packet". The patient and, when appropriate, "his/her family is informed about the outcomes of care, including unanticipated outcomes". This policy was last released on 06/2017.

2. Hospital policy titled, "Assessment/Re-Assessment Interdisciplinary Patient", original date 08/2013, policy number H-PC 02-001, indicated "Notification Responsibilities" when an assessment reveals a "change in condition" the nurse assigned to the patient or supervising the care of the patient "is responsible" for notification. Notify the Nursing Supervisor of patient change in condition. "Others are notified" as appropriate and per facility designation, "including notification of patient's family" and/or significant other. "Document" change of condition, "notification" and interventions in the medical record. This policy was last released on 06/2018.

3. Review of patient # 7's closed MR (medical record), indicated the following:
A. The "Nurses notes" dated 09/21/2018 by WN # 2, indicated the following:
1. Pressure ulcer location: L heel.
2. Wound onset type: acquired after admission.
3. Stage: suspected deep tissue injury (DTI-unstageable).
4. Wound length: 4.7 cm (centimeters).
5. Wound width: 4.7 cm.
6. Wound depth: unable to determine.
7. Comments: "100 % purple, fluid filled, skin intact, soft on palpation".
B. The "Plan of Care" for "Risk for Impaired Skin/Tissue Integrity" was updated on 09/21/2018 by WN # 2 (Wound Care RN), which indicated the "target date changed" from 09/19/2018 to achieve new objective date of 09/29/2018. The "Intervention" indicated to "notify MD/WCC/PT/Family" of infection and/or deterioration in wound status.
C. The MR lacked the appropriate documentation which indicated the POA (Power of Attorney) family member was notified related to the unanticipated pressure ulcer the patient acquired on his/her left heel.

4. In interview on 01/03/2019 at approximately 12:20 pm with staff member WN # 2, confirmed that "for a new wound" it gets "documented in the change in condition", and in the "comment section is where I usually document" if the nurse or physician and/or "family" was notified. "If not there not sure what to tell you".

5. In interview on 01/03/2019 at approximately 2:10 pm with administrative staff member A # 4 (Chief Clinical Officer-CCO), confirmed the person who found the wound "should have notified the family". It should have been "documented in the comment section if the family was notified".

Based on document review, and interview the registered nurse failed to follow the policy and procedure and document turning/repositioning the patient q2h (every 2 hours) as per physician order for fourteen (14) out of the one hundred and four (104) turning/repositioning opportunities, failed to ensure the POA (Power of Attorney) family member was notified related to a change in condition, and failed to ensure the POA family member was notified prior to the patient being discharged for 1 of 10 patients. (Patient # 7)

Findings include:

1. Hospital policy titled, "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds", original date 08/2012, policy number H-PC 10-003, indicated "skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure... related wounds or skin issues". The preventative and healthy skin care interventions are utilized and may include "repositioning at intervals determined per patient's risk level and condition". This policy was last released on 06/2016.

2. Hospital policy titled, "Discharge Planning", original date 01/2006, policy number H-PC 02-004, indicated the purpose was to "ensure that patients have a smooth and safe transition from" H # 1 to "his/her next level of care. The roles of the "Discharge Planning" at the time of discharge, the following tasks will be accomplished by the disciplines indicated: "Nurses: contact the patient's family/caregiver to inform them of the discharge date". This policy was last released on 06/2017.

3. Hospital policy titled, "Patient Rights and Responsibilities", original date 09/1991, policy number H-PC 09-001, indicated "rights and responsibilities referred to in this policy shall be protected and exercised for each patient and his/her family/guardian" at H # 1. The list of "Patient Rights and Responsibilities is provided to each patient at admission as part of the admission packet". The patient and, when appropriate, "his/her family is informed about the outcomes of care, including unanticipated outcomes". This policy was last released on 06/2017.

4. Hospital policy titled, "Assessment/Re-Assessment Interdisciplinary Patient", original date 08/2013, policy number H-PC 02-001, indicated "Notification Responsibilities" when an assessment reveals a "change in condition" the nurse assigned to the patient or supervising the care of the patient "is responsible" for notification. Notify the Nursing Supervisor of patient change in condition. "Others are notified" as appropriate and per facility designation, "including notification of patient's family" and/or significant other. "Document" change of condition, "notification" and interventions in the medical record. This policy was last released on 06/2018.

5. Review of patient # 7's closed MR (medical record), indicated the following:
A. The "Physician verbal order" to "Reposition" dated 09/12/2018 at 10:11 pm by MS # 2 (Physician), indicated to reposition the patient "q2h" (every 2 hours).
B. The MR "Nurses notes" dated 09/13/2018 through 09/21/2018 (date pressure ulcer to L (left) heel was discovered), related to turning/repositioning the patient every two (2) hours, lacked the following documentation of turning/repositioning:
1. On 09/13/2018 at 4:00 am, 6:00 am, and 2:00 pm.
2. On 09/14/2018 at 2:00 am, 10:00 am, and 3:00 pm.
3. On 09/15/2018 at 4:00 am, 6:00 am, and 8:00 am.
4. On 09/18/2018 at 8:00 pm.
5. On 09/19/2018 at 4:00 pm.
6. On 09/20/2018 at midnight, 6:00 am, and 6:00 pm.
C. The "Nurses notes" dated 09/21/2018 by WN # 2, indicated the following:
1. Pressure ulcer location: L heel.
2. Wound onset type: acquired after admission.
3. Stage: suspected deep tissue injury (DTI-unstageable).
4. Wound length: 4.7 cm (centimeters).
5. Wound width: 4.7 cm.
6. Wound depth: unable to determine.
7. Comments: "100 % purple, fluid filled, skin intact, soft on palpation".
D. The "Plan of Care" for "Risk for Impaired Skin/Tissue Integrity" was updated on 09/21/2018 by WN # 2 (Wound Care RN), which indicated the "target date changed" from 09/19/2018 to achieve new objective date of 09/29/2018. The "Intervention" indicated to "notify MD/WCC/PT/Family" of infection and/or deterioration in wound status.
E. The MR lacked the appropriate documentation which indicated the POA (Power of Attorney) family member was notified related to the unanticipated pressure ulcer the patient acquired on his/her left heel, and notified prior to the patient being discharged.

6. In interview on 01/03/2019 at approximately 12:20 pm with staff member WN # 2, confirmed that "for a new wound" it gets "documented in the change in condition", and in the "comment section is where I usually document" if the nurse or physician and/or "family" was notified. "If not there not sure what to tell you".

7. In interview on 01/03/2019 at approximately 2:10 pm with administrative staff member A # 4 (Chief Clinical Officer-CCO), confirmed the person who found the wound "should have notified the family". It should have been "documented in the comment section if the family was notified". The "nurse should have notified the family that the patient was being discharged".

8. In interview on 01/03/2019 at approximately 2:25 pm with administrative staff member A # 3, confirmed "the turning documentation has missing turns".