Failure to Consistently Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
A deficiency was identified when a resident, admitted with acute respiratory failure with hypoxia and dysphagia, was not consistently turned and repositioned every two hours as required by their care plan and facility policy. Multiple observations over two days showed the resident lying on their back for extended periods, with only minor adjustments such as a pillow under the left arm, and no evidence of repositioning. A family member also reported not seeing the resident turned or repositioned during their visit. Interviews with nursing staff confirmed the importance of regular turning and repositioning to prevent skin breakdown, especially given the resident's severe cognitive impairment, total dependence on activities of daily living, and high risk for pressure ulcers as indicated by their Braden score and care plan. Record reviews further confirmed that the resident was dependent for all ADLs, had a severely impaired mental status, and was at risk for skin breakdown due to immobility and contractures. Despite these risk factors and clear care plan interventions, the required two-hourly turning and repositioning was not consistently implemented. The facility's own policy also emphasized individualized repositioning schedules for residents at risk of pressure injuries, which was not followed in this case.