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Based on policy and procedure review, medical record review, and staff interview, the nurse executive failed to ensure facility expectations, and policy, were met and implemented, related to documentation of the repositioning of patients who have poor skin integrity for 5 of 5 patients whose records were reviewed. (Pts. #1, #2, #3 - open records; and #4 and #5 - closed records.)

Findings:
1. Review of the policy and procedure "prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds", HD WC 01-001, NCD POL:614, with a "release date" of 2/28/14, indicated:
a. On page 3 under "Components", it reads in section 5.: "Preventative and healthy skin care interventions are utilized and may include but not limited to: a. Reduce pressure, friction & shear 1) Repositioning at intervals determined per patients risk level and condition. A minimum of every 2 hours for those patients determined to be at moderate to high risk...".

2. Review of medical records indicated:
a. Pt. #1 had a nursing plan for the patient that included "turns q 2 hours" with documentation indicating 2 hour repositioning did not occur on:
A. 11/9/14 between 5:59 PM and 10:22 PM.
B. 11/12/14 between 5:45 AM and 9:08 AM.

b. Pt. #2 had a nursing plan for the patient that included "turns q 2 hours" with documentation indicating 2 hour repositioning did not occur on:
A. 9/11/14 between 5:15 AM and 9:23 AM.
B. 9/12/14 from 7:29 PM, and 12:45 AM on 9/13/14.
C. 9/13/14 between 12:45 AM and 3:31 AM.

c. Pt. #3 was admitted on 11/1/14 at 2:30 PM and had a nursing plan for the patient that included "turns q 2 hours" with documentation indicating 2 hour repositioning did not occur on:
A. 11/1/14 and 11/2/14 lacked any 2 hour documentation for either day.

d. Pt. #4 had a nursing plan for the patient that included "turns q 2 hours" with documentation indicating 2 hour repositioning did not occur on:
A. 9/11/14 between 5:18 PM and 8:00 PM (with both indicating "supine" position, so no repositioning occurred)
B. 9/15/14 between 1:40 PM and 4:31 PM.
C. 9/17/14 between 2:23 AM and 6:34 AM, and 6:34 AM and 10:00 AM.
D. 9/18/14 between 12:25 PM and 4:54 PM.
E. 11/7/14 between 7:20 PM and 11:24 PM.

e. Pt. #5 had a nursing plan for the patient that included "turns q 2 hours" with documentation indicating 2 hour repositioning did not occur on:
A. 8/6/14 between 4:00 AM and 6:49 AM, and from 6 PM to 9:30 PM.
B. 8/7/14 between 3:45 AM and 6:38 AM.

f. Pt. #5 also had right and left heel pressure ulcers noted on admission, with wound care to be each Monday, Wednesday and Friday. Documentation indicated that the 8/6/14 (Wednesday) and 8/18/14 (Monday) wound care was not documented as having been done by either the wound care nurse, or a floor nurse.

3. Interview with staff member #11, the facility wound nurse, at 11:12 AM on 11/14/14, indicated:
a. The facility uses a variety of different mattresses, and overlays, depending on a patient's particular skin care problems or needs.
b. Regardless of the type of mattress a patient may have, even with alternating pressure mattresses, every patient is to be repositioned every two hours.

4. Interview with staff member #18, the nurse manager, at 3:00 PM and 3:45 PM on 11/14/14, indicated:
a. A physician order is not required to place patients on an every 2 hour repositioning protocol/care plan. Nursing staff does this based on the Braden Scale results and per facility protocol/expectations.
b. Review of the medical records for patients #1 through #5, as listed in 2. above, indicates that nursing staff are not documenting every two hour repositioning as required per the facility policy and standard of practice.
c. Pt. #3 is lacking documentation for the first two days of admission that they were repositioned every 2 hours.
d. No documentation of wound care could be found for Pt. #5 for 8/6/14 and 8/18/14, so that the wound care orders were not documented as performed as written.