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Based on record review and interview, the hospital failed to assure that the patient received care in a safe setting, in that Patient #1 had orders that were not followed during his care at the hospital. Patient #1 did not receive a bath/shower on 8 of 11 days that he was an inpatient. There was a physician order to turn the patient Q2 hours to start on 2/22/2019 at 0542 AM, but there was no documentation of the patient being turned on 4 times on 2/22/2019, 10 times on 2/23/2019, 6 times on 2/24/2019, 8 times on 2/25/2019, and 6 times on 2/26/2019.

Findings include:

Patient #1 was in the rehabilitation hospital for post operative rehabilitation, he also had a pressure ulcer on his coccyx. The pressure ulcer was unstable and described as a scratch upon admission (2/18/2019). However on 3/1/2019 when Patient #1 was discharged from the rehabilitation hospital, and he was taken to an acute care hospital. Patient was admitted with pneumonia and a Stage 4 decubitus.

The medical record documents Patient #1 did not have a bath on 2/19/2019; 2/21/2019; 2/24/2019; 2/25/2019; 2/26/2019; 2/27/2019; 2/29/2019; and 3/1/2019, that is a total of 8 days that the patient did not have a bath or shower and no documentation as to why his bathing was not done.

On 2/22/2019 at 0542 AM, physician order to Turn patient q 2 hours, the medical record documents on 2/22/2019, Patient #1 missed turns at 14:00, 16:00, 18:00 and 07:00 equal to 4 turns not completed and no documentation why the patient missed being turned. On 2/23/2019, Patient #1 was not turned at 08:00, 10:00, 12:00, 14:00,16:00, 18:00, 20:00, 22:00, 24:00 and 07:00 AM which is 10 Physician orders that were not completed. On 2/24/2019, Patient #1 was not turned at 07:00; 09:00; 11:00; 13:00; 15:00; and 17:00, which is 6 physician orders that were not completed. On 25/2019, Patient #1 was not turned at 15:00, 19:00; 21:00; 23:00; 01:00; 03:00; 05:00; and 07:00 which resulted in 8 physician orders not completed. On 2/26/2019, Patient #1 was not turned at 20:00, 22:00, 24:00; 2:00; 4:00; and 06:00, there were 6 physician orders that were not completed.

An interview with Personnel #1 on 7/9/2019 as we reviewed Patient #1 chart together, confirmed the patient was not bathed and was not turned every 2 hours as ordered. Patient #1 was asked if she could explain why these basic nursing skills were not accomplished for Patient #1. Personnel #1 said, "No." Personnel #1 was asked if the failure of turning a patient as ordered and not bathing/showering a patient could lead to skin breakdown, Personnel #1 said "Yes."

Based on record review and interview, the hospital failed to have organized staff to ensure the health and safety of patients, in that, Patient #1 was not bathed/showered on 8 of 11 days that he was an inpatient. There was a physician order to turn Patient #1 Q 2 hours to start on 2/22/2019 at 0542 AM, but there was no documentation of Patient #1 being turned on 4 times on 2/22/2019, 10 times on 2/23/2019, 6 times on 2/24/2019, 8 times on 2/25/2019, and 6 times on 2/26/2019.

Findings include:

Patient #1 was in the rehabilitation hospital for post operative rehabilitation, he also had a pressure ulcer on his coccyx. The pressure ulcer was unstable and described as a scratch on the left buttocks upon admission (2/18/2019). However on 3/1/2019 when Patient #1 was discharged from the rehabilitation hospital, and he was taken to an acute care hospital. Patient #1 was admitted on 3/1/2019, with pneumonia and a Stage 4 decubitus.

The medical record documents Patient #1 did not have a bath on 2/19/2019; 2/21/2019; 2/24/2019; 2/25/2019; 2/26/2019; 2/27/2019; 2/29/2019; and 3/1/2019, that is a total of 8 of 11 days that the patient did not have a bath or shower and no documentation as to why his bathing was not done.

On 2/22/2019 at 0542 AM, physician order to Turn patient Q 2 hours, the medical record documents on 2/22/2019, Patient #1 missed turns at 14:00, 16:00, 18:00 and 07:00 equal to 4 turns not completed and no documentation why the patient missed being turned. On 2/23/2019, Patient #1 was not turned at 08:00, 10:00, 12:00, 14:00,16:00, 18:00, 20:00, 22:00, 24:00 and 07:00 AM which is 10 Physician orders that were not completed. On 2/24/2019, Patient #1 was not turned at 07:00; 09:00; 11:00; 13:00; 15:00; and 17:00, which is 6 physician orders that were not completed. On 25/2019, Patient #1 was not turned at 15:00, 19:00; 21:00; 23:00; 01:00; 03:00; 05:00; and 07:00 which resulted in 8 physician orders not completed. On 2/26/2019, Patient #1 was not turned at 20:00, 22:00, 24:00; 2:00; 4:00; and 06:00, there were 6 physician orders that were not completed.

An interview with Personnel #1 on 7/9/2019 as we reviewed Patient #1 chart together, confirmed the patient was not bathed and was not turned every 2 hours as ordered. Patient #1 was asked if she could explain why these basic nursing skills were not accomplished for Patient #1. Personnel #1 said, "No." Personnel #1 was asked if the failure of turning a patient as ordered and not bathing/showering a patient could lead to skin breakdown, Personnel #1 said "Yes."