Failure to Implement and Document Resident Repositioning for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement and document a consistent process for repositioning residents at risk for pressure ulcers. Three residents with significant mobility impairments and incontinence, who required assistance for bed mobility, did not have evidence of being repositioned according to their care plans. The care plans for these residents specified turning and repositioning per a rounding schedule, but there was no established schedule or documentation process for staff to follow. Record reviews showed sporadic and infrequent documentation of turning and repositioning in nursing progress notes, with large gaps between entries and no detailed information about the positions used or the frequency of repositioning. Certified Nurse Assistant (CNA) documentation was absent, and interviews revealed that CNAs were unclear about the rounding schedule and lacked a standardized method to record repositioning tasks. Observations confirmed that residents remained in the same position for extended periods during the survey. Interviews with staff, including a CNA and a Unit Manager, confirmed the absence of a formal process for documenting repositioning. The Unit Manager acknowledged that only nurses were documenting turning and positioning in progress notes, and that CNAs did not have a system in place to record these interventions. This lack of a structured process and documentation increased the risk of pressure ulcer development among residents requiring frequent repositioning.