Deficiencies in Repositioning, Wound Care, Enteral Nutrition, and Incontinence Care
Penalty
Summary
Multiple deficiencies were identified in the care and services provided to several residents, including failures in implementing individualized turning and repositioning schedules, accurate wound assessment and documentation, proper administration of enteral nutrition and medications, and timely incontinence care. For example, residents with impaired mobility and at risk for pressure injuries were not repositioned according to their care plans and posted schedules, with observations showing prolonged periods in the same position and staff interviews confirming lapses in documentation and practice. In one case, a resident was observed on their back for extended periods over several days, and staff admitted to not documenting repositioning due to a new charting system. Wound care deficiencies were also noted, with two residents having open wounds that were not accurately assessed or documented by nursing staff. Observations revealed visible wounds that were not recorded in weekly skin assessments, and wound care nurses were unaware of their existence until prompted by surveyors. Additionally, a resident with a left hip wound did not have the ordered dressing in place, and the wound was left exposed to friction from an incontinence brief, contrary to physician orders and facility policy. Enteral nutrition and medication administration were not performed in accordance with physician orders and clinical standards for two residents. Staff failed to check gastric residuals before feeding, did not maintain appropriate head-of-bed elevation during feeding, and did not flush feeding tubes with the prescribed amount of water before and after medication administration. In one instance, enteral tubing was left uncapped and undated at the bedside, and staff proceeded to use it after only wiping it with alcohol, despite infection prevention standards. Timely incontinence care was also lacking, with one resident waiting over three hours for assistance after requesting to be changed, and staff interviews confirmed that such delays were not acceptable.