F0684

D

Failure to Reposition Dependent Residents per Two-Hour Standard of Care

Byram, Mississippi Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide turning and repositioning assistance according to standards of care and facility policy for two dependent residents who required ADL support. The facility’s ADL CARE POLICY dated August 2023 states that residents are to receive appropriate treatment and services to ensure all ADL needs are met daily. For Resident #1, observations on 1/12/26 at 9:30 AM showed the resident resting in bed on her back with the head of the bed elevated, with a family member present. At 2:00 PM, the family member reported she had been in the room continuously since before 9:30 AM and that the resident had not been turned or repositioned during that time. CNA #2, assigned to Resident #1 on the 7:00 AM–3:00 PM shift, confirmed at 2:56 PM that she had turned/repositioned the resident only once prior to 9:30 AM and acknowledged that the resident was supposed to be turned every two hours while in bed. Record review showed Resident #1 had diagnoses including cerebral infarction and dysphagia, severely impaired cognitive skills, and was assessed as dependent for bed mobility.

For Resident #2, on 1/12/26 at 11:15 AM, observation and interview revealed the resident was lying on his back in bed, alert and oriented, reporting bilateral leg discomfort and stating he had not been repositioned since approximately 5:00 AM when a male CNA turned him onto his back. At 11:22 AM, CNA #1 entered and repositioned him onto his left side with a foam wedge, stating this was the first time she had turned him that day. In a 3:22 PM interview, CNA #1 stated the resident required repositioning every two hours and that she did not know when he had last been turned before 11:22 AM. The RN Supervisor, interviewed at 3:30 PM, stated he had been responsible for the care of both residents until approximately noon, had arrived at about 6:43 AM, and was not aware that Resident #2 had not been turned during the 7:00 AM–3:00 PM shift until 11:22 AM, nor that Resident #1 had not been turned for approximately five hours. He attributed the postponement of care to lack of communication and acknowledged he had not checked on Resident #2. The Administrator and DON both stated their expectations that nurses and RN Supervisors supervise care and that residents be turned/repositioned every two hours and as needed to avoid discomfort and damage to skin integrity. Record review for Resident #2 showed admission with diagnoses including congestive heart failure and cervical region spondylosis with myelopathy.