Failure to Reposition Resident as Required for Pressure Ulcer Prevention
Penalty
Summary
A resident with a history of cerebral infarct, hemiplegia, muscle wasting, and contractures was admitted to the facility and assessed as being at moderate risk for pressure ulcers, with documented dependence on staff for turning and repositioning. The resident's care plan specified that turning and repositioning should occur at least every two hours and as needed. However, observations on a specific day showed the resident remained positioned on their right side for several hours, from 9:09 AM through 1:07 PM, without being repositioned. During interviews, a CNA stated that dependent residents are typically turned 2-3 times per shift, and an LPN confirmed that the resident had not been repositioned as required and would instruct the CNA to complete the task.