Failure to Reposition Dependent Resident at High Risk for Pressure Injuries
Penalty
Summary
The facility failed to ensure that a totally dependent resident with existing skin breakdown was repositioned every two hours as care planned and expected by facility policy. The resident, an older adult with hemiplegia and hemiparesis following cerebral infarction, vascular dementia, a stage 3 sacral pressure ulcer, frontotemporal neurocognitive disorder, and hypertensive heart disease, was observed on 3/23/26 at 3:26 pm lying in bed on his right side with the head of the bed elevated. At that time, his family member reported that he had been lying on his right side since around 10:00 am that morning and that she had been waiting for staff to help her turn him because he already had a pressure sore. The CNA assigned to the resident stated at 3:45 pm that she had been on duty since 7:00 am and believed the last time she repositioned the resident was at 9:00 am. She reported that staffing was reduced, with only three CNAs on the unit instead of the usual four, and that she could not reposition the resident by herself and could not always find someone to assist. She also stated she did not know the resident’s sister would help reposition him and acknowledged the resident should be repositioned every two hours and had a wound on his heel. The LPN assigned to the resident stated she was not sure when the resident was last turned and that the CNA was responsible for repositioning. The DON confirmed the resident had a left heel wound being monitored, that the resident could not turn himself, and that it was expected he be turned and repositioned every two hours. The resident’s care plan documented he was at high risk for skin breakdown, required total care and dependent assistance for mobility, and should be repositioned every two hours and as needed, consistent with the facility’s pressure injury prevention policy requiring repositioning of residents with or at risk of pressure injuries on an individualized schedule.
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