Failure to Reposition Resident with Pressure Ulcer as Ordered
Penalty
Summary
A resident with a history of cervical spine fracture, quadriplegia, and a sacral pressure ulcer was not turned or repositioned for approximately five hours, contrary to physician orders and the resident's care plan, which required repositioning every two hours. Documentation for turning and repositioning during the overnight shift was missing, and a CNA reported not providing this care after midnight, citing the resident being asleep and claiming the resident always refused to be turned. However, another CNA stated the resident never refused repositioning and was always willing to participate in care. The facility's policies required regular repositioning for immobile residents to prevent skin breakdown and maintain skin integrity. The Director of Nursing confirmed that turning and repositioning are essential for both comfort and assessment of skin condition, and that care should have been provided and documented. The lack of adherence to the care plan and physician's orders resulted in the resident not receiving necessary care to prevent complications related to pressure injuries.