Failure to Reposition Residents to Prevent Skin Breakdown
Penalty
Summary
The facility failed to ensure that residents with limited mobility were regularly repositioned to prevent skin breakdown. Multiple residents reported that staff only repositioned them upon request, and observations confirmed that residents remained in the same position for extended periods without the use of positioning aids such as pillows or wedges. One resident noted that staff applied cream to her buttock area, which was observed to be slightly pink and blanchable, but she was not informed about the condition of her skin. Another resident reported soreness from prolonged sitting and was not observed to be repositioned during the survey period. Documentation showed that one resident was not turned at all on several days. Staff interviews revealed that the restorative aide responsible for mobility and repositioning services was covering approximately 70 residents across three buildings, and that CNAs could assist with turning and repositioning, but nurses were described as too busy to help. Residents expressed concerns about inadequate cleaning and the risk of skin breakdown, with some reporting recurrent UTIs and discomfort from prolonged immobility. The electronic health records did not consistently reflect the residents' actual skin conditions or repositioning needs.