Failure to Reposition Dependent Resident as Ordered, Resulting in Skin Redness and Indentations
Penalty
Summary
The facility failed to ensure that a resident who was totally dependent on staff for all activities of daily living, including turning and repositioning, was provided care as ordered to prevent skin breakdown. The resident, who had severe cognitive impairment, dementia, diabetes, and other significant medical conditions, had a care plan and physician's order requiring turning and repositioning every two hours. Despite these orders and facility policies emphasizing the importance of repositioning to prevent pressure ulcers, staff did not consistently turn or reposition the resident as required. Multiple interviews and observations revealed that the resident remained on her back for extended periods, with staff and family members confirming that turning and repositioning were not performed as ordered. Observations showed the resident lying on wrinkled bed linens, and staff interviews confirmed that the resident had not been turned or repositioned during the day shift. Documentation and direct statements from CNAs and the DON further confirmed the lack of adherence to the turning schedule. As a result of this failure, the resident was observed with multiple red areas, indentations, and red lines on her upper thighs, buttocks, and lower back, attributed to prolonged pressure and wrinkled sheets. The lack of timely repositioning and failure to follow the care plan and physician's orders directly contributed to the resident's skin changes and increased risk for pressure ulcer development.
Plan Of Correction
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident identified was turned upon identification and transferred to her wheelchair. Additionally, a task was added to the POC charting to turn and reposition every 2 hours. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Any dependent resident has the potential to be affected by the practice. On 3/19/25, Director of Staff Development educated on repositioning and turning of this resident to the CNA on duty. On 3/20/25, this resident was picked up by therapy to assist with increased range of motion and activity. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/19/25, Director of Staff Development initiated education on repositioning and turning policy. Director of Staff Development will conduct daily visual audits, Monday through Friday, of three residents turning and repositioning. How the facility plans to monitor its performance to make sure that the solutions are sustained: Audit results will be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. If 95% compliance is achieved after 90 days, the issue will be resolved within QAPI. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 20th, 2025.