Failure to Implement Scheduled Repositioning for Resident at Risk of Skin Breakdown
Penalty
Summary
A review of the health record for a resident with Parkinson's disease and muscle weakness revealed that the resident required extensive assistance with physical functioning, including bed mobility, transfers, eating, and toileting. The Minimum Data Set assessment indicated the resident needed substantial or maximal assistance for various movements such as rolling, sitting, and transferring. The care plan identified the resident as being at risk for skin breakdown and included an intervention to turn and reposition the resident every two hours. However, documentation showed that on multiple dates, the resident was not turned and repositioned as required by the care plan. This was confirmed during an interview and record review with the director for staff development, who acknowledged the resident was not turned every two hours. The facility's policy on repositioning states that bedbound residents should be repositioned at least every two hours to prevent skin breakdown and provide pressure relief.