Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely repositioning and incontinence care for a resident who was dependent on staff for activities of daily living. Multiple observations over several days showed the resident lying in bed in the same position, with no evidence of being repositioned or having incontinence care provided for extended periods, sometimes up to five hours. Staff interviews confirmed that the resident was not checked, changed, or repositioned during these intervals, despite facility policy and the resident's care plan requiring repositioning at least every two hours and peri care after each incontinence episode. The resident in question had a history of cerebral infarction, dementia, mood disturbance, and anxiety, and was assessed as severely cognitively impaired and fully dependent for ADLs. The resident also had a pressure ulcer related to immobility and was at risk for further skin breakdown, as indicated by a Braden Scale score of 13 and frequent skin moisture. Observations documented the resident wearing heavily saturated briefs with foul odor, and staff acknowledged that the care provided did not meet the required frequency. The Director of Nursing confirmed the expectation for two-hourly checks and repositioning, and that refusals of care should be documented, but also stated there was no facility wound care policy.