Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
Staff failed to provide incontinence care and turning/repositioning at least every two hours for a resident who was totally dependent on staff for activities of daily living. During a two-hour observation period, there was a persistent malodor coming from the resident's room, and no incontinence care or repositioning was provided. A nurse entered the room to provide gastrostomy tube care but did not check for incontinence needs. At the end of the observation, the resident was found with a urine-saturated brief, a wet flat sheet with brown discoloration, and a mattress with pooled liquid under the buttocks. The resident's sacral pressure ulcer dressing was also saturated with urine. Staff interviews confirmed that the resident was unable to assist with ADLs and was fully dependent on staff. The wound care director stated that staff are expected to turn and reposition residents and provide incontinence care every two hours and as needed. The resident's medical records indicated a low BIMS score and total dependence on staff for care. Despite these needs, the required care was not provided during the observed period.