Failure to Provide and Document Required Turning and Repositioning for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, major depressive disorder, and mood disorder, who was dependent on staff for bed mobility and transfers, did not consistently receive turning and repositioning as required for pressure ulcer prevention and treatment. The resident had a stage 2 sacral pressure ulcer that resolved but later reopened, and the care plan specified repositioning at least every two hours. Certified nurse aide documentation revealed multiple instances across several months where the resident was not turned and repositioned as required, both before and after the wound reopened. The wound care physician provided specific instructions for turning and repositioning every 1-2 hours in bed and every 30 minutes while in a chair, but documentation and staff interviews confirmed that these interventions were not consistently implemented. Certified nurse aides reported that the electronic documentation system only allowed them to record turning and repositioning per shift, not every two hours, and that they did not reposition the resident while in a wheelchair. There were also several days where no documentation was present, indicating the care may not have been provided. Interviews with nursing staff and management confirmed awareness of the care requirements but also highlighted limitations in the documentation system and inconsistent adherence to the prescribed interventions. The lack of detailed, timely documentation and the failure to follow the care plan and physician orders led to the resident not receiving the necessary treatment and care for pressure ulcer prevention and management.