Failure to Follow Turning Schedule and Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow the care plan and facility policies for the prevention and treatment of skin breakdown for one resident with a pressure ulcer. Record review showed that the resident had a facility-acquired stage 3 pressure ulcer, which progressed to a stage 4 ulcer and remained at that stage over several months. The resident's care plan included following facility protocols for skin breakdown prevention and treatment. However, review of the turning logs revealed that on multiple occasions, the resident was documented as being positioned on the same side for consecutive turning intervals, rather than being repositioned as required. The Interim Director of Nursing confirmed that staff should have turned the resident and acknowledged the documentation discrepancies, noting that the resident's fiancé may have also moved the resident, which could have contributed to the inconsistent records.