Failure to Reposition Residents at Risk for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards by not ensuring that three residents at moderate risk for pressure ulcers were turned and repositioned as care planned. One resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had a Braden score of 13 indicating moderate risk. The resident’s MDS showed moderately impaired cognition and a need for maximal assistance with rolling. The resident’s care plan, initiated shortly after admission, required assistance with turning and repositioning at least every two hours, but the treatment nurse and the DON both confirmed there was no documented evidence that this turning and repositioning occurred every two hours as ordered. Another resident was admitted with a stage 4 sacral pressure ulcer, muscle weakness, and adult failure to thrive, and had a Braden score of 13, also indicating moderate risk. This resident’s MDS showed severely impaired cognitive skills and total dependence on staff for rolling to either side. The interdisciplinary wound management care plan directed staff to reposition the resident every two hours or as often as necessary. During record review with the treatment nurse, it was determined there was no documented evidence that the resident was turned and repositioned every two hours, despite the care plan intervention and the resident’s dependence on staff for mobility. A third resident, admitted with type 2 diabetes mellitus, muscle weakness, and essential hypertension, had a Braden score of 14, indicating moderate risk, and required moderate assistance with rolling according to the MDS. This resident also had a sacrococcygeal pressure ulcer and an interdisciplinary wound management care plan that required repositioning every two hours or as often as indicated. The treatment nurse and the DON confirmed there was no documented evidence that this resident was turned and repositioned every two hours. The facility’s pressure ulcer prevention policy required nursing staff to monitor interventions for effectiveness and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques weekly, but the lack of documentation of turning and repositioning for all three residents demonstrated that these interventions were not implemented as required.
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