F0686

D

Failure to Reposition Resident With Multiple Stage 4 Pressure Ulcers

South Pasadena, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries by not ensuring a resident was repositioned every two hours as care planned. The resident was initially admitted and later readmitted with multiple stage 4 pressure ulcers, including to the sacral region, left hip, right buttock, and left buttock. The resident’s care plans, dated 11/7/2025 and 2/3/2026, documented impaired skin integrity with stage 4 pressure injuries to the sacrococcyx, left ischium, and left posterior hip, with interventions that included keeping affected areas clean and dry, monitoring for adverse changes, and turning and repositioning every two hours or as needed. The MDS dated 2/5/2026 indicated the resident had intact cognitive skills for daily decision making, bilateral lower extremity impairment, required supervision or touching assistance for rolling, and had stage 4 pressure ulcers.

On observation, the resident was seen lying on his back in bed on multiple occasions. During an interview, the treatment nurse stated the resident needed help with repositioning while awake and that, although the resident previously used a timer on his phone while asleep, he now needed significantly more help due to wearing a leg brace. In a concurrent observation and interview, the resident reported that staff had not offered or assisted with repositioning. The CNA interviewed confirmed that the resident could not move his legs, required staff to carry his legs when repositioning from side to side, and was supposed to be repositioned every two hours to avoid pressure injuries and prevent current wounds from worsening.

The CNA further stated that during his 7 AM to 3 PM shift he had only repositioned the resident once around 9 AM and that no other staff had repositioned the resident during that time. He acknowledged that the resident was not efficient with repositioning himself, needed assistance with managing the leg brace during turns, and that he did not follow the standard procedure of repositioning the resident every two hours during his eight-hour shift. The Director of Rehabilitation confirmed the resident was paraplegic, unable to use his lower extremities, wore a knee brace that limited movement, and required staff to hold the leg during repositioning. The DON stated the resident needed staff assistance with repositioning every two hours and that staff were required to offer repositioning even if residents declined. The facility’s policy on Prevention of Pressure Injuries, revised 7/12/2023, directed staff to reposition residents as indicated on the care plan, which was not followed in this case.