Failure to Reposition High-Risk Resident to Prevent Pressure Ulcers
Penalty
Summary
Staff failed to implement required interventions to prevent pressure ulcers for one resident who was at high risk due to multiple medical conditions, including vascular dementia, failure to thrive, impaired healing from peripheral vascular disease, and protein calorie malnutrition. The resident was severely cognitively impaired, dependent on staff for transfers and repositioning, and had a care plan specifying frequent turning, repositioning, and keeping the skin clean and dry. Despite these documented interventions, the resident was observed sitting in a Broda chair for extended periods without being repositioned by staff. Observations showed that the resident remained in the same position in the Broda chair for several hours, with no staff assistance in repositioning during that time. Interviews with the assigned CNA confirmed that the resident was not repositioned throughout the observed period. The unit manager and DON both stated that the expectation was for staff to reposition residents who are unable to do so themselves at least every two hours. The failure to follow these interventions placed the resident at increased risk for developing pressure ulcers.