Failure to Follow Physician's Repositioning Order for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained or maintained their highest practical physical well-being. Specifically, the facility did not follow a physician's order to reposition the resident every two hours on the left side and every two hours on the right side while in bed. The resident, who had diagnoses including Parkinson's disease, right ankle contracture, and mobility abnormalities, was dependent or required substantial assistance for bed mobility and transfers. Observations on multiple occasions showed the resident lying on his back with the head of the bed elevated, and interviews with CNAs revealed that repositioning was not performed as ordered. Instead, staff reported only pulling the resident up in bed or adjusting pillows under his arms, rather than turning his body as specified in the physician's order. The facility's policies required that all physician orders be specific and complete, and that staff provide interventions according to individualized care plans and professional standards. Despite these policies, staff interviews indicated that repositioning was done only when the resident requested it or according to his preference to remain on his back, rather than following the prescribed schedule. The DON acknowledged that the order should have been discontinued if it was not being followed, but at the time of the survey, the order remained in place and was not being implemented as written.