Failure to Reposition Dependent Resident as Ordered
Penalty
Summary
A deficiency was identified when staff failed to assist a resident with turning and repositioning as required by her care plan and medical needs. The resident, who was admitted with diagnoses including venous insufficiency, diabetes, and peripheral vascular disease, was documented as being dependent for mobility and repositioning. Multiple observations throughout the day showed the resident lying on her back in bed for extended periods without being turned or repositioned by staff. Staff interviews confirmed that the resident was not routinely turned, with one CNA stating she only checked on the resident when she had time, despite the resident being incontinent and requiring checks every two to three hours. The resident was cognitively intact and able to communicate her needs, but staff reported that she refused to get out of bed or be moved. Despite these refusals, there was no evidence that staff made consistent efforts to turn or reposition her according to her care needs and orders. The lack of regular repositioning placed the resident at risk for skin breakdown, as noted in the report.