Failure to Reposition High-Risk Resident With Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors identified that the facility failed to provide pressure ulcer care and preventive repositioning for a resident with a high risk for skin breakdown. The resident was admitted with a stroke, dementia, muscle weakness, adult failure to thrive, and a stage 3 sacral pressure ulcer, and an admission MDS documented total dependence for turning and repositioning with impairments in both upper and lower extremities. A Braden Scale assessment showed a score of 9, indicating very high risk for pressure ulcer development, and the care plan called for turning and repositioning and skin checks every 2 hours. Despite this, on multiple observations on the same day, the resident was seen lying in bed on his back with the head of the bed elevated approximately 45–60 degrees, without positioning pillows or wedges, and remained on his back for four hours without being turned. The wound NP stated that turning and repositioning is expected every 2 hours even with an air mattress and that wedges or pillows were available, and a CNA confirmed that pillows or wedges could be used and that it was not a problem to get the resident off his back, demonstrating that the facility did not implement the ordered repositioning regimen.
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