Failure to Reposition Bedbound Resident with Pressure Ulcer as Required
Penalty
Summary
The facility failed to ensure that a resident with a stage IV pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident, who had severe cognitive impairment and was dependent on staff for repositioning, was not repositioned as required by her care plan and physician orders during a morning shift. Both CNA A and CNA B, who were involved in the resident's care that day, confirmed that the resident was not repositioned until approximately 2:30 PM, despite the expectation and care plan directive for repositioning at least every two hours. Record review indicated that the resident had a history of pressure ulcers, severe protein-calorie malnutrition, and required two-person assistance for repositioning. The care plan and physician orders specified frequent repositioning and the use of mobility bars to aid in turning. Interviews with staff, including the charge nurse, ADON, and DON, confirmed that the standard practice was to reposition bedbound residents every two hours to prevent further skin breakdown and deterioration of existing wounds. However, on the day in question, the resident remained in the same position for an extended period, and staff did not follow the established protocols. Observations and interviews revealed that the resident was found in bed with a wound vac in place and had not been repositioned according to her care plan. Staff interviews indicated a lack of communication and follow-through regarding the resident's repositioning needs, with both CNAs and the charge nurse unaware that the resident had not been repositioned during the morning shift. The facility's policy required that residents' abilities in activities of daily living not deteriorate unless unavoidable, but this standard was not met in this instance.