Failure to Follow Physician Order for Two-Hour Turning and Repositioning
Penalty
Summary
The facility failed to provide care according to physician orders and resident needs by not ensuring that a paraplegic resident requiring total care was turned and repositioned every two hours as ordered. The resident’s medical record showed a physician’s order dated January 6, 2026, directing staff to turn and reposition the resident every two hours on every shift. However, the Treatment Administration Record for March 2026 contained only one checkbox per eight-hour shift for turning and repositioning, rather than documentation for every two hours. The DON confirmed that the order had not been correctly entered into the software to allow for every-two-hour checks and that there was no place for nurse aides to document the two-hourly turning and repositioning, acknowledging that the existing documentation did not follow the physician’s orders. This deficiency involved one of ten residents reviewed (Resident R2), who had diagnoses including paraplegia and required total care, and was cited under 28 Pa. Code: 201.18(a)(b)(1)(3) Management and 28 Pa. Code: 211.12(d)(1)(5) Nursing services.
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