F0686

D

Failure to Reposition High-Risk Resident With Stage 4 Pressure Ulcer

Long Beach, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer prevention and care by not turning and repositioning a resident with an existing stage 4 pressure ulcer at least every two hours as required. The resident had multiple risk factors, including type 2 DM without complications, severe protein-calorie malnutrition, and a documented stage 4 PU to the sacrococcyx measuring 5.7 cm x 3.6 cm x 2.5 cm. The resident’s MDS showed he was dependent on staff for rolling from left to right, and his Braden Scale score of nine indicated high risk for pressure ulcer development. The resident’s care plan documented an alteration in skin integrity with an actual stage 4 pressure injury related to immobility and included interventions to turn and reposition at least every two hours and to use pillows as repositioning devices.

Despite these documented needs and interventions, observations on multiple occasions the same day showed the resident lying on a low air loss mattress positioned on his left side with a wedge under his right buttock, without evidence of being turned or repositioned for over four hours. CNA 1 stated the resident could not turn himself and relied on staff to assist with turning and repositioning at least every two hours to prevent skin breakdown. LVN 1 stated that the treatment nurse and charge nurses were responsible for ensuring residents were turned and repositioned every two hours and as needed, and the DON stated licensed nurses were responsible for making sure CNAs turned residents every two hours. The facility’s policy on prevention of pressure ulcers required residents in bed to have their position changed at least every two hours or more frequently as needed, which was not followed in this case.