Failure to Provide Timely Assistance with Toileting and Bed Mobility
Penalty
Summary
The facility failed to provide necessary assistance with toileting and bed mobility for a resident who was admitted with cancer and pressure ulcers. The resident was cognitively intact but required staff assistance for bed mobility and was totally dependent for toileting. According to the care plan, the resident needed one-person assistance for bed mobility and maximum assistance with a bedpan for bowel movements. On the evening of 04/08/2025, staff placed the resident on a bedpan but did not inform the night shift that the resident was still on the bedpan. The night shift staff provided medication and assessment but were unaware of the bedpan and did not reposition the resident during their shift. The resident remained on the bedpan from approximately 9:15 PM until 7:15 AM the following morning, when staff discovered the bedpan during a wound assessment. As a result, the resident sustained a possible deep tissue injury on the left gluteal fold. Staff interviews confirmed that residents with pressure ulcers or at risk for them should be repositioned at least every two hours, and that this resident required assistance to turn due to pain and weakness. The failure to communicate and provide necessary assistance led to the resident remaining on the bedpan for an extended period, resulting in injury.