According to the National Database of Nursing Quality, the prevalence rate of hospital-acquired pressure ulcers (HAPUs) for intensive care units (ICUs) ranges between 7.14% and 14.35%. In the United States, prevalence of pressure ulcers (PUs) among patients, according to the National Pressure Ulcer Advisory Panel, ranges from 1.3 to 3 million; the costs are projected to be $2.2-$3.6 billion a year. The purpose of this quality improvement project was to implement and evaluate the effects of intervention strategies on the incidence of HAPUs. As part of this project, the organizational policy for the prevention of HAPUs was revised and a pressure ulcer prevention (PUP) pilot program for the ICU was implemented. The setting was a 22-bed ICU located in Orange County, California. Implementation of the PUP strategies began at the end of January 2015; strategies were based on available literature. These included synchronized turning every 2 hours, photographing at-risk areas, and application of silicone dressings as moisture barriers to the sacrococcyx and heels. For 7 months in 2015, after implementation of the PUP strategies, there were no reported HAPUs. However, at month 8, a number of staffing changes, including loss of the wound care nurses and PUP champions, causing a loss of institutional knowledge, was intensified by the practice of rotating experienced ICU nurses familiar with the PUP strategies out of the unit. A follow-up audit revealed that the PUP strategies were only sporadically implemented. Nurses are normally the first to discover the emergence of PUs and the decline of the skin iv condition. Recommendations for the ongoing quality improvement process include maintenance of key champions, institutionalization/publication of PUP strategies, regular audits of performance with reports to staff, and academic detailing to improve performance as necessary. Optimum implementation of PUP quality improvement requires an inclusive preventive program with evidence-based practice, consistent managerial support, and accountability. Nurses are in a position to contribute to the collaborative effort to reduce HAPUs.