Failure to Provide Timely Incontinence Care and Repositioning for Resident with Pressure Ulcer
Penalty
Summary
A resident who was recently admitted to the facility developed a pressure wound on her buttocks and a urinary tract infection (UTI) after arrival. The resident reported that the facility was short staffed and that she had experienced significant delays in receiving incontinence care, sometimes waiting for hours after calling for assistance. On at least one occasion, she contacted a family member to call the nursing station on her behalf due to the prolonged wait for care. During an observation, a CNA and a physical therapist found the resident's undergarment dry but with large streaks of dried feces, and dried, caked feces were present between the gluteal fold. The resident's labia and gluteal fold were reddened, and there was a small open area on her coccyx. The CNA confirmed that she had not provided incontinence care or repositioned the resident during her shift until the time of the observation, and that the wound nurse had provided care during a dressing change. The resident is obese, incontinent of bowel and bladder, and unable to reposition herself without assistance from two staff members. Interviews with staff and review of records indicated that there was no documentation of a pressure wound or UTI at the time of admission, and the wound was first documented two days after admission. Facility policy requires that all residents receive appropriate care to decrease the risk of skin breakdown, including cleaning skin at the time of soiling and at routine intervals, and providing incontinence care to keep residents dry and comfortable. The failure to provide timely incontinence care and repositioning contributed to the resident's skin breakdown and development of a pressure wound.