For decades, aged care facility residents at risk of pressure ulcers have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week. Yet, pressure ulcers still develop.

We used a cross-sectional survey of eighty randomly selected medical records of residents aged ≥ 65 years from eight Australian Residential Aged Care Facilities to determine the number of residents at risk of PUs, the use of two-hourly repositioning, and the presence of pressure ulcers in the last week of life.

Despite 91 per cent (73/80) of residents identified as being at risk of PUs and repositioned two-hourly 24/7, 34 per cent (25/73) died with one or more pressure ulcers.

Sharp, C.A., Schulz Moore, J.S. & McLaws, ML. Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?. Bioethical Inquiry 16, 17–34 (2019). https://doi.org/10.1007/s11673-018-9892-3