Failure to Reposition Resident as Ordered for Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention care in accordance with physician orders and the resident’s care plan, specifically by not repositioning a resident every two hours. Surveyor observations over multiple days showed that Resident #8, who was care planned and ordered to be turned and repositioned every two hours, remained in the same or similar positions for extended periods without evidence of repositioning. On one day, the resident was first observed lying on the right side facing the wall, and later that day was observed supine with a wedge at the feet. The following day, the resident was observed supine without a wedge in the morning and again in the early afternoon and mid-afternoon in the same position, with no staff observed providing repositioning assistance during these intervals. Record review showed that Resident #8 was admitted with diagnoses including a Stage 4 pressure ulcer of the sacral region, severe unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a history of TIA and cerebral infarction without residual deficits. The care plan, initiated in early September and revised in early October, included pressure injury preventive interventions requiring turning and repositioning every two hours. Physician orders dated mid-August directed staff to assist and/or encourage the resident to turn and position every two hours for pressure relief each shift. Multiple LPNs and GNAs, as well as the ADON, confirmed in interviews that facility protocol and expectations were to round and reposition residents every two hours, using a clock on staff badges as a guide, and that residents unable to move themselves were supposed to be turned. Despite this, the observations of Resident #8 demonstrated that the ordered and care-planned repositioning was not carried out as required.
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