Failure to Implement and Document Repositioning Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and document the required repositioning interventions for four residents who were assessed as being at risk for pressure ulcer development. Each of these residents had significant mobility impairments, such as hemiplegia, anoxic brain damage, paraplegia, or other abnormalities of gait and mobility, and were dependent on staff for turning and repositioning in bed. Their care plans specifically included interventions for turning and repositioning every two hours and as needed, in accordance with facility policy and recognized standards of practice. Observations and interviews with staff confirmed that these residents were unable to reposition themselves and relied entirely on staff for this care. However, a review of the electronic health records and point of care documentation for a specific date revealed significant gaps in the documentation of turning and repositioning. For each of the four residents, the documented times for repositioning did not meet the care plan requirement of every two hours, with long intervals between recorded repositioning events. The Director of Nursing confirmed that the documentation did not show that the residents were turned and repositioned as frequently as required by their care plans. The facility's own policies require that residents who are bed-bound and dependent on staff be repositioned at least every two hours, and that care plans be implemented as written to address identified risks. The lack of documented evidence that these interventions were carried out as planned constituted a failure to implement the care plans and facility policy, potentially exposing the residents to the risk of pressure ulcer development.