Failure to Provide Repositioning, Toileting, and Pressure Relief for Dependent Resident
Penalty
Summary
A resident with a history of stroke and identified as a moderate risk for pressure injury, as indicated by a Braden Scale score of 14, was admitted to the facility and required staff assistance for all activities of daily living, including bed mobility, transfers, eating, and toileting. The resident's care plan included the use of pressure relieving devices in bed and/or wheelchair to prevent skin impairment. Despite these documented needs and interventions, the resident was observed without an air mattress or other pressure relieving device on the bed, and a provider order for an air mattress was not placed until 24 days after the risk was identified. Additionally, the resident was observed in a wheelchair for an extended period without being repositioned or offered toileting assistance. Over a span of several hours, no staff were seen providing these necessary services, and the resident remained in the same position. When eventually returned to bed and provided personal care, the resident was found to have a red, blotchy, non-raised rash on the lower abdomen and mid-to-lower back. The Director of Nursing Services confirmed that the resident was not on a scheduled turning or toileting check and change program, despite expectations for such care at least every two hours.