Failure to Reposition Resident With Stage 4 Pressure Ulcer and Report Refusals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a Stage 4 pressure ulcer was turned and repositioned in accordance with the resident’s care plan. The resident had diagnoses including muscle weakness and a displaced subtrochanteric fracture of the left femur, moderately impaired cognitive skills, and required assistance with mobility and activities of daily living. The care plan identified the resident as having a pressure ulcer or risk for pressure ulcer development related to weakness, pain, impaired mobility, incontinence, and risk for impaired circulation, and directed staff to monitor, remind, and assist the resident to turn and reposition every two hours and as needed. A separate care plan also documented that the resident was resistive to care related to non-compliance with turning and repositioning, with interventions to educate the resident on possible outcomes of not complying with treatment or care. Surveyor observations showed that after wound care and a bed bath, CNAs turned and positioned the resident slightly toward the right side with a pillow placed lengthwise from the left side of the neck under the left shoulder down to the waistline, and this same positioning was observed at multiple times later that day. During an interview, a CNA stated they had changed the resident’s diaper but did not reposition the resident because the resident refused to turn, and the CNA did not inform the charge nurse or any licensed nurse of this refusal. The Treatment Nurse and DON both stated that CNAs are expected to follow the repositioning schedule and report refusals to the charge nurse so that licensed staff can provide education, encouragement, and follow-up. The facility’s policy on Prevention and Management of Pressure Injuries indicated that residents should be encouraged to reposition and that the facility will promote a turning schedule and reposition frequently as needed.
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