An elderly woman died with severe bedsores after she was not regularly turned by staff at a Cambridgeshire care home, an inquest has heard.
Ana Dunmore, 74, who had dementia, was not turned for nine days while at the Old Vicarage in Littleport in 2009.
A hearing in Huntingdon was told nurses had advised staff to move Ms Dunmore at least every two hours.
The home's assistant manager, Danny Dew, told the inquest he could not explain why it had not happened.
District nurses had spoken to staff in June 2009 after noticing bedsores on Ms Dunmore's lower back and on her heels and ankles.
The inquest heard a chart showed she was turned at 20:00 BST on 15 June, then not again until 09:35 BST and 23:00 BST the following day.
She was then turned at 04:00 BST on 17 June and then not at all for nine days between 18 and 27 June.
When asked why only one member of staff had turned Mrs Dunmore when two were needed to prevent friction burns, the home's manager, Michael Paling, said "perhaps only one had signed the chart".
Mrs Dunmore had been at the Old Vicarage since early 2008 and was moved to another home shortly before she died of dementia, pneumonia and pressure sores on 10 July 2009.
The inquest continues.