Failure to Consistently Reposition High-Risk Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered turning and repositioning interventions every two hours for a resident with significant risk factors and an existing pressure ulcer. The resident was admitted with severe sepsis with septic shock, ALS, and ventilator dependence, and was assessed on the MDS as having a BIMS score of 0, being totally dependent on staff for all care, and always incontinent of bowel and bladder. The MDS documented that the resident was at risk for developing pressure ulcers and required a turning/repositioning program. Subsequent wound documentation showed the development of a sacral shearing injury that progressed to a stage 3 pressure ulcer not present on admission, with measurements indicating deterioration over time and the need for strict repositioning every two hours. On the day of survey observation, the resident was repeatedly observed lying on the left side with pillows to the back at multiple time points over several hours. Nursing staff interviews confirmed that the resident was supposed to be turned and repositioned every two hours due to the stage 3 pressure ulcer. However, the electronic medical chart for that day showed the last documented turn to the left side at 10:05 a.m., and by 1:47 p.m. the wound nurse acknowledged the resident should have been turned around noon but remained on the left side. Multiple CNAs and nursing staff reported there was no organized or set process in the facility to know when residents needed to be turned and repositioned. CNAs stated they tried to remember when to turn residents, that residents often waited more than two hours, sometimes up to three hours, and that turning could be delayed more than 30 minutes past the intended time, especially when staffing was short or staff were busy. The risk manager confirmed the facility did not have a set process for determining when it was time to turn and reposition residents, despite a written policy requiring repositioning at least every two hours for residents unable to reposition themselves and applying this standard to residents with stage 3 pressure injuries.
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