Failure to Reposition to Avoid Bed Sores, Pressures Sores and Wounds
Failure to Reposition to Avoid Bed Sores, Pressures Sores and Wounds

Failure to Reposition Residents Causing Pressure Sores

Failure to reposition residents causes pressure sores. According to: Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 12. Pressure Ulcers: A Patient Safety Issue by Courtney H. Lyder, Elizabeth A. Ayello, pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm Hg is considered the average. Thus, keeping the external pressure less than 32 mm Hg should be sufficient to prevent the development of pressure ulcers. However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to hemodynamic instability and comorbid conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group of patients. Pressure ulcers can develop within 2 to 6 hours.

There are several areas on the body where if the pressure is not off loaded by repositioning and proper support surfaces.  The National Pressure Ulcer Advisory Panel (NPUAP) coordinated the development of a uniform terminology, test methods and reporting standards for support surfaces. Theses guidelines provide an objective means for evaluating and comparing support surface characteristics.

The AHRQ website for providers and clinicians in a patient safety article – pressure ulcers remain a major health problem affecting approximately 3 million adults. In 1993, pressure ulcers were noted in 280,000 hospital stays, and 11 years later the number of ulcers was 455,000. The Healthcare Cost and Utilization Project (HCUP) report found from 1993 to 2003 a 63 percent increase in pressure ulcers, but the total number of hospitalizations during this time period increased by only 11 percent. Pressure ulcers are costly, with an average charge per stay of $37,800.

Failure to Reposition – Nursing Homes Have a Duty to Prevent Pressure Sores

Federal regulations contained in 42 CFR 483 and in the surveyors guidance tool called Ftags nursing homes have a duty to prevent pressure sores which are not clinically unavoidable.  This means provide the necessary nutrition, hydration, hygiene, assistance with turning and repositioning.

Ftag 314 – 42 CFR 483.25 (c) Pressure sores

Based on the comprehensive assessment of a resident, the facility must ensure that –

  • A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and
  • A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing”

Ftag 314 Intent

  • Promote the prevention of pressure ulcer development
  • Promote healing of pressure ulcers that are present
  • Prevent development of new pressure ulcers

Failure to Reposition – Avoidable versus Unavoidable Pressure Ulcers

Definitions of Avoidable and Unavoidable Pressure Ulcers (Centers for Medicare and Medicaid, 2004)

Avoidable Pressure Ulcer:

“Avoidable” means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. (483.25c/TagF314)

 Unavoidable Pressure Ulcer:

“Unavoidable” means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. (483.25c/TagF314)

Failure to Reposition – Minnesota Pressure Sore Reposition and Turning Regulation

Minnesota Statutes 2008, section 144A.04, is amended by adding a subdivision to read: Subd. 12. Resident positioning. Notwithstanding Minnesota Rules, part 4658.0525, subpart 4, the position of residents unable to change their own position must be changed based on the comprehensive assessment and care plan.

Why Do Residents Get Pressure Sores?

According to the following are common reasons which contribute to pressure sores:

  • Age – oxygen levels in the skin decrease over time
  • Lack of mobility – effects the circulation and blood flow due to a failure to reposition residents
  • Poor Diet – nutrition is necessary to maintain good skin health
  • Moisture – wet skin is at greater risk for pressure ulcers
  • Mental, neurological and other physical problems, effects ability to advocate for themselves and pain responses
  • Friction and shearing – these forces can assist in skin break down
  • Bed sheets and wheelchairs, with wrinkled areas or hard objects – can cause abrasion and cuts leading to skin breakdown
  • Pressure ulcers in the past – the skin may be compromised and at greater risk due to previous open sores

Turning and repositioning of nursing home residents who require assistance with mobility is essential and one of the most common forms of elder abuse and neglect found in Minnesota nursing homes.

According to the Pressure Ulcer Prevention Training Module, prepared by The Anna and Harry Borun Center for Gerontological Research: nationally, the prevalence of PU among nursing home residents is 14% for high-risk individuals.  In a study with a sub-sample of 98 PU risk residents who were unable to reposition themselves independently, based on our performance assessment. All these residents then were in need of two-hour repositioning to prevent PU development. And all had medical record documentation that they were receiving it. But when we used wireless thigh movement monitors to detect actual repositioning, we found that only 26% of these residents were repositioned an average of every three hours or less. Moreover, their average longest time in one position was 5.6 hours, and ranged from 4 to 12 hours.

NPUAP provides the following Pressure Ulcer Prevention Points

  1. Risk Assessment
  2. Skin Care
  3. Nutrition
  4. Mechanical Loading and Support Surfaces
  5. Education

A full PDF file with this information can be found here

If you or a loved one is the victim of elder abuse or neglect in the form of preventable pressure sores or other injury, contact attorney Kenneth L. LaBore for a free consultation at 612-743-9048 or at 1-888-452-6589 or by email at

NPUAP Stage 4 Pressure Ulcer, Pressure Sore, Decubitus Ulcer
NPUAP Stage 4 Pressure Ulcer, Pressure Sore, Decubitus Ulcer


Bedsores from Failure to Reposition
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