Failure to Provide Timely Turning and Repositioning for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when staff failed to implement regular and timely turning and repositioning for a resident who was dependent on assistance for bed mobility and at risk for pressure ulcers. The resident, admitted with multiple diagnoses including hematoma of the skin, chronic kidney disease, muscle weakness, and limited mobility, was assessed as being at risk for skin breakdown and unable to turn or reposition independently. The care plan identified the need for assistance with activities of daily living and bed mobility, but did not include specific interventions for turning and repositioning every two hours. Multiple observations and interviews revealed that the resident remained in the same position for extended periods and was not aware of the need for regular repositioning. Staff interviews confirmed that the resident had not been turned as required, despite facility policy and professional standards indicating the necessity of such care for immobile residents. The lack of consistent implementation of pressure injury prevention measures placed the resident at risk for skin breakdown.