Failure to Provide Positioning Assistance and Implement Vision-Related Interventions
Penalty
Summary
The facility failed to provide appropriate positioning assistance for a resident with impaired cognition, dementia, and physical limitations who was dependent on staff for activities of daily living and used a wheelchair. Observations over several days revealed that the resident was repeatedly seated in a wheelchair without footrests, resulting in her heels being elevated off the ground and only the tips of her slippers touching the floor. Staff interviews confirmed that footrests were not in use, and staff were unaware of their absence. The care plan directed staff to assist with repositioning and transfers but lacked specific instructions for wheelchair positioning, and the facility policy did not provide guidance on wheelchair positioning assistance. Additionally, the facility failed to implement a care plan intervention for another resident who required eyeglasses and had a history of skin integrity issues on the bridge of the nose. The care plan specified that a band-aid should be applied to the metal nose piece of the glasses for extra padding. Multiple observations showed the resident wearing glasses without the required padding, resulting in an indent and purple discoloration of the skin under the metal nose piece. Staff interviews confirmed awareness of the skin issue but revealed that the intervention was not being followed, and there was no documentation or monitoring of the resident's skin condition as required by the care plan. The facility's policies on activities of daily living required services to maintain mobility and nutrition and called for documentation and evaluation of interventions, but did not provide specific direction for wheelchair positioning or eyeglass-related skin protection. The lack of adherence to care plan interventions and absence of clear policy guidance contributed to the deficiencies observed in the care and treatment of both residents.