Failure to Reposition Bedbound Residents with Pressure Ulcers
Penalty
Summary
Staff failed to provide appropriate pressure ulcer care and prevention for two residents who were immobile and unable to reposition themselves. Multiple observations over two consecutive days showed that both residents remained lying on their backs for extended periods, despite care plans and medical records indicating the need for repositioning every two hours or as needed. Certified Nursing Assistants (CNAs) and other staff did not consistently implement these interventions, and one CNA stated that repositioning was not necessary for one of the residents, contrary to established protocols. Resident 190 had a history of severe medical conditions, including aphasia, chronic respiratory failure, hemiplegia, and a stage 4 pressure ulcer on the sacral/coccyx region, as well as deep tissue damage on the left heel. The resident was non-ambulatory, required extensive assistance with bed mobility, and was cognitively impaired. Despite these needs, observations confirmed that the resident was not turned or repositioned as required, and the wound size remained unchanged over several days. The care plan specifically called for repositioning every two hours, but this was not consistently followed. Resident 546 also had significant medical issues, including pneumonia, respiratory failure, diabetes, and lower extremity embolism and thrombosis. This resident was similarly non-ambulatory, cognitively impaired, and dependent on staff for repositioning. Observations revealed that the resident was left lying on her back for long periods, and staff reported difficulties in repositioning due to lack of appropriate equipment, such as a wedge pillow. The facility's own policy emphasized the importance of frequent repositioning, especially for residents with existing pressure ulcers, but these guidelines were not adhered to in practice.