Failure to Implement Repositioning Care Plan for Resident with Mobility Impairments
Penalty
Summary
A deficiency was identified when staff failed to implement a resident's care plan interventions for regular repositioning and body alignment checks. The resident, who had a history of cerebral infarction, cerebrovascular disease, and hemiplegia/hemiparesis, had care plan directives requiring staff to check body alignment when passing by the room, provide a pressure reduction mattress, assist with positioning for comfort, and monitor and assist with repositioning at least every two hours. The air mattress manufacturer’s manual also emphasized that the mattress is not a substitute for frequent repositioning. During observations, the resident was seen lying on her back for an extended period without evidence of repositioning. Multiple staff interviews confirmed that the resident had not been repositioned as required, with one LPN incorrectly stating that repositioning was unnecessary due to the use of an air mattress. Other staff, including a CNA, CNA Supervisor, and Treatment Nurse, acknowledged that the resident should have been repositioned every two hours, as per the care plan.