Failure to Individualize and Document Pressure Ulcer Repositioning Interventions
Penalty
Summary
The facility failed to identify and implement an appropriate turning and repositioning schedule for a resident with a pressure ulcer, as well as to document when staff performed repositioning. The resident had a diagnosis of pressure ulcers, diabetes, and neurocognitive disorder with Lewy body dementia, and was identified as severely cognitively impaired and at risk for pressure ulcer development. The care plan indicated the need for turning and repositioning every 2 to 3 hours and as needed, but there was no evidence that a specific, individualized schedule was established or documented in accordance with professional standards of practice. Observations and interviews revealed that staff repositioned the resident, but did not consistently document when repositioning occurred. Nursing staff reported that repositioning was done every 2 hours, but this was not always recorded, and the care plan lacked personalized interventions to promote wound healing. The CNA report sheet did not reflect the required interventions, and staff were not required to use a checklist to document hourly rounding or repositioning. The wound care nurse noted that repositioning every 2 hours was not sufficient to promote wound healing for this resident. The facility's care planning policy required individualized care plans, but the resident's plan did not include specific, personalized interventions for pressure ulcer prevention and care. The lack of documentation and individualized planning contributed to the failure to minimize the risk of further pressure ulcer development and ensure that appropriate interventions were implemented.