Failure to Consistently Reposition Dependent Resident Leads to New Pressure Ulcers
Penalty
Summary
A resident who was unable to reposition independently and was dependent on staff for turning and repositioning developed two new pressure ulcers while in the facility. The resident reported that staff did not consistently turn him/her every two hours as required. Medical record review confirmed that the resident had two wounds upon admission and was under the care of a Wound Nurse Practitioner, with preventative measures including turning/repositioning and use of a low air loss mattress. Despite these interventions, documentation showed multiple instances where the resident was not turned or repositioned according to protocol over several dates and time periods. The facility's own policy required that residents unable to reposition themselves be turned every hour. Interviews with staff confirmed that both turning/repositioning and the use of a low air loss mattress were necessary and that one did not replace the need for the other. Documentation and interviews indicated that staff failed to consistently implement these preventative measures, resulting in the development of new pressure ulcers for the resident.