Failure to Provide Timely Repositioning for Resident with Pressure Ulcer
Penalty
Summary
A deficiency occurred when a resident with paraplegia, arthritis, and anxiety disorder, who was identified as being at risk for skin breakdown and having a stage 3 pressure ulcer, did not receive timely assistance with repositioning as required by her care plan. The care plan specified that the resident should be repositioned every two hours while in bed to prevent further skin breakdown. Observations showed that the resident remained lying on her back for nearly three hours without being repositioned, despite staff being aware of her need for frequent turning due to her pressure ulcer. Documentation and staff interviews confirmed that the resident had not been repositioned according to the prescribed schedule. The resident required extensive assistance with activities of daily living, including bed mobility and transfers, and had a chronic wound that required daily dressing changes. Staff interviews and documentation indicated that the resident's care plan and physician orders for wound care and repositioning were not followed. The facility was unable to provide a repositioning policy when requested. The deficiency was identified through direct observation, interviews with staff, and review of the resident's medical records and care plan.