The intent of the study was to explore the relationship between implementing a pressure ulcer prevention bundle and its effect on pressure ulcer incidence in an adult ICU setting. Pressure Ulcers are costly and impact the health of adult ICU patients. Despite advances, a large percentage of ICU patients suffer from hospital acquired pressure ulcers in intensive care units. Information about the relationship of bundled evidence-based pressure ulcer prevention interventions and the incidence of pressure ulcers demands further study. This study compared pressure ulcer(PU)incidence rates before and after the implementation of a PU prevention bundle. The study group consisted of a convenience sample of n= 286 adult ICU patients in an urban hospital. The bundle included an nursing educational component, nursing interventions linked to Braden sub scale scores and factored in patient co-morbidity. Data collected included: demographics, incidence rates, and Braden sub scale scores. Descriptive data was collected and analyzed. PU incidence rates ranged from 10 to 17% in the ICU prior to the implementation of the PU prevention bundle. PU incidence fell to 0% during the study period. Implementation of a pressure ulcer prevention bundle reduced PU incidence rates for the study population. The study also revealed gaps & barriers in the implementation of components of the bundle. Further study is required to explore the affects of systematic gaps & barriers on implementation of bundled practice and to explore relationships between variables in the study that may affect outcomes.