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Based on review of documentation and interview, it was determined that the governing body was not responsible for services provided in the hospital in that staff failed to follow established facility policy and procedure in the care of a patient. The facility also failed to follow established requirements set forth in 25 TAC 133.41 (f)(4)(A).

Findings were:

Facility policy number Nursing 11.276 titled "Pressure Sores, Prevention and Treatment" states, in part, "I. Trustpoint Hospital Specifications
a. Prevention of Pressure Sores/Ulcers
i. Upon admission and at least once every shift, all patients will be assessed for their risk of pressure ulcer development using the Braden Risk Assessment for Pressure Score (RAPS) Scale located on the electronic Nursing Admission Form and/or the Nursing Documentation Form (paper)."

During a review of the clinical record for patient #10, Braden Risk Assessments were not performed on the following dates and times:
? 2-1-13/night shift
? 2-2-13/night shift
? 2-3-13/night shift
? 2-6-13/day shift
? 2-6-13/night shift
? 2-7-13/night shift
? 2-10-13/night shift
? 2-11-13/day shift
? 2-15-13/day shift
? 2-15-13/night shift
? 2-16-13/night shift
? 2-17-13/night shift
? 2-20-13/day shift
? 2-21-13/day shift

The lack of documented Braden Risk Assessments per policy for Patient #10 was confirmed in an interview with the Director of Nursing on 05/08/13.