Failure to Provide Required Turning and Repositioning for At-Risk Resident
Penalty
Summary
Staff failed to provide necessary services to maintain optimal skin integrity for one resident who was at risk for pressure ulcers. The resident, who had multiple diagnoses including spinal stenosis, Alzheimer's disease, morbid obesity, and was always incontinent of bowel and bladder, required moderate assistance for bed mobility and was care planned to be turned and repositioned every two hours and as needed. Observations over several hours showed the resident remained in the same position in bed, and interviews with CNAs confirmed that the resident had not been turned or repositioned during their shifts. The resident also confirmed she was unable to reposition herself and was not routinely turned by staff. Further review revealed that the resident's care plan included the need for regular turning and repositioning, but this intervention was not reflected in the facility's electronic charting system or on the paper kardex. The DON confirmed these omissions and acknowledged that the required tasks were not listed as they should have been. Staff interviews corroborated that the resident was not turned or repositioned as required by her care plan, resulting in a failure to provide necessary services to prevent pressure ulcers.