Failure to Implement Care Plans for Repositioning and Meal Supervision
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies related to skin integrity and nutritional supervision. For one resident with a history of pressure injuries, the care plan required repositioning every two hours due to altered skin integrity and a re-opened pressure injury to the sacrococcyx. Observations revealed that the resident remained seated in a wheelchair at a 45-degree angle for an extended period, with staff confirming that the resident had not been repositioned since 11 a.m. The resident was dependent on staff for transfers and mobility, as documented in the Minimum Data Set, and the Director of Nursing acknowledged the care plan's requirement for frequent repositioning. Another resident's care plan indicated the need for supervision and assistance with all meals, as well as staff presence during mealtimes to redirect the resident from feeding others. Observations showed that the resident was eating alone in her room without staff supervision, and a CNA confirmed that no staff were present to assist or monitor the resident during the meal. The Director of Nursing noted that the resident's behavior of feeding others could pose a safety issue, especially for those with swallowing problems. The facility's policy emphasized the importance of care plans in addressing residents' medical, nursing, and psychosocial needs, but these plans were not followed in the observed cases.