Failure to Safely Position Dependent Resident Results in Skin Injury
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical conditions, including cerebral atherosclerosis, peripheral vascular disease, multiple sclerosis, abnormal posture, dementia, diabetes, and dysphagia, was not safely positioned during a meal. The resident was placed in a reclining wheelchair at a 45-60 degree angle, causing her contracted knees and shins to be elevated above the dining table. Staff parked her diagonally next to the table, resulting in her shins being pressed against the table edge. This positioning led to linear, reddened areas and small wounds on both shins, as observed by the wound care nurse. The resident's daughter reported that during a visit, she found her mother with her shins pressed tightly against the table, causing pain and deep indents. The daughter released the wheelchair brakes and moved her mother away from the table, noting the marks and reporting the incident to staff. The CNA assigned to the resident stated that she had positioned the resident at the table with a nurse and believed the resident's legs were not touching the table when she left. However, it was acknowledged that the table may have been moved by another resident, resulting in the injury. Documentation showed that the resident was dependent on staff for all activities of daily living and had severe cognitive impairment, making her unable to communicate her needs effectively. The care plan did not address the skin concerns resulting from the incident. The facility's policy required interventions to provide a safe environment and prevent skin injuries, but these were not adequately implemented in this case, leading to minor traumatic wounds on the resident's shins.