Failure to Prevent Recurrence of Pressure Ulcer Due to Inadequate Repositioning
Penalty
Summary
A resident with a history of pressure ulcers and multiple risk factors, including impaired mobility, incontinence of bowel and bladder, and a recent femur fracture, was observed lying on his back in bed on an air mattress for an extended period. During two separate observations on the same day, the resident remained in the same position, and he reported that he had not been turned since the previous night and was experiencing pain and developing a sore. Upon further observation by nursing leadership, the resident's lower back was found to be bright red with a small open area on the left side of the sacrum, consistent with a pressure ulcer. The resident's care plan included interventions such as regular turning and repositioning, use of a pressure-reducing mattress, and monitoring for skin breakdown. Despite these documented interventions, staff failed to implement the required turning and repositioning schedule, as confirmed by the resident's statement and direct observation. The facility's policy and wound care consult also emphasized the need for ongoing pressure reduction and repositioning, but these measures were not consistently followed, resulting in the recurrence of a pressure ulcer.