Failure to Consistently Turn and Reposition Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care by not consistently turning and repositioning two residents with existing pressure ulcers every two hours or as needed. Both residents had significant medical conditions that increased their risk for pressure injuries, including functional quadriplegia, diabetes, muscle weakness, and end stage renal disease for one resident, and acute kidney failure, diabetes, muscle weakness, and a Stage IV pressure ulcer for the other. Documentation and interviews confirmed that the required turning and repositioning tasks were left blank on several shifts, indicating the care was not performed as required. Resident records and assessments showed that both individuals were dependent on staff for mobility and at high risk for developing or worsening pressure ulcers. One resident had multiple pressure ulcers, including an unstageable ulcer on the sacrum and deep tissue injuries on the right gluteus and left heel. The other resident had a Stage IV pressure ulcer on the sacral region. Despite these conditions, neither resident was on a formal turning and repositioning program according to their Minimum Data Set assessments. Interviews with facility staff, including an LVN and the DON, confirmed that the lack of documentation meant the turning and repositioning was not done. Facility policy and national guidelines both require regular repositioning of residents at risk for pressure injuries, but this was not followed for these two residents, as evidenced by incomplete documentation and staff statements.