Failure to Document Resident Repositioning per Facility Policy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one of six residents reviewed. According to the facility's repositioning policy, documentation should include the resident's position, the name and title of the caregiver, any problems or complaints, refusals of care with reasons, and the signature and title of the person recording the data. For the resident in question, clinical records indicated a requirement for repositioning per facility protocol, but there was no documented evidence of a turning and repositioning program, nor consistent documentation of position changes and body realignment. Interviews with the Administrator and DON confirmed the absence of documentation showing that the resident was repositioned or turned at least every two hours as required by policy.