Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
A resident with a history of encephalopathy, hepatomegaly, and COPD was readmitted to the facility and had a documented Stage 4 pressure ulcer on the sacro-coccyx. The resident's care plan and physician orders required repositioning every two hours and the use of a low air loss mattress to prevent further skin breakdown. Observations and interviews revealed that the resident was not repositioned according to the facility's turning schedule, remaining in a supine position when they should have been turned to the left or right side. Staff interviews confirmed awareness of the repositioning protocol, and the resident was noted to require substantial assistance for mobility and turning. Despite established protocols and staff knowledge, the resident was not consistently repositioned as required. The facility's policy emphasized the importance of high-quality care and adherence to evidence-based practices, including regular repositioning to promote wound healing and prevent further deterioration. The failure to reposition the resident as scheduled placed the resident at risk for worsening of the existing Stage 4 pressure ulcer.