Failure to Prevent Pressure Ulcer Due to Prolonged Bedpan Use
Penalty
Summary
A resident with moderate cognitive impairment and multiple complex medical conditions, including depression, anxiety, cancer, muscle weakness, metabolic encephalopathy, diabetes, and acute kidney failure, was dependent on staff for all activities of daily living. The resident's care plan and kardex required staff to reposition the resident every two to three hours and provide assistance with toileting, including anticipating toileting needs and checking/changing as needed. Despite these instructions, a nursing assistant placed the resident on a bedpan and failed to return, neglecting to inform the next shift that the resident remained on the bedpan. During the following shift, another nursing assistant interacted with the resident, providing food, fluids, and repositioning, but did not check or change the resident or notice the bedpan. The resident, who was more fatigued and less communicative than usual, did not alert staff to her situation. The oversight continued for approximately eleven and a half hours until a registered nurse discovered the resident still on the bedpan during a routine check. The resident subsequently developed multiple deep tissue injuries on the buttocks, as confirmed by wound assessments and hospital evaluation, with the injuries corresponding to the outline of the bedpan. Interviews with staff revealed a lack of communication regarding the resident's status and care needs, as well as a failure to follow the care plan's directives for frequent repositioning and toileting assistance. The care plan did not specify the use of a bedpan, and staff assumptions about the resident's ability to communicate her needs contributed to the incident. The prolonged pressure from the bedpan resulted in actual harm, including the development and progression of deep tissue injuries.