Failure to Implement and Document Pressure Ulcer Repositioning Schedule
Penalty
Summary
A resident with significant cognitive decline and multiple unstageable pressure ulcers, including a deep tissue injury, did not receive the necessary treatment and services to promote healing and prevent new ulcers. The resident's comprehensive care plan required extensive assistance from one to two staff members to turn and reposition her in bed every two hours and as necessary. However, review of the scheduled tasks and treatment record for the relevant month did not show documentation of repositioning. Observations on a single day revealed the resident remained in the same position for at least four hours, with no evidence of repositioning. Interviews with staff indicated a lack of clarity and consistency regarding the documentation and oversight of repositioning. A CNA acknowledged the resident required repositioning every two hours but was unsure where to document this intervention. An RN stated that CNAs were responsible for repositioning and that she had communicated this expectation, while the DON confirmed that staff were expected to follow the turning schedule, but the medical record did not have a designated place for documentation. The facility's policy required interventions to be documented in the care plan and communicated to staff, with compliance documented in weekly summary charting.