Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
A deficiency was identified when staff failed to provide timely repositioning and incontinence care for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had diagnoses including renal disease, Alzheimer's disease, and was always incontinent of bowel and bladder, required maximal to total assistance for mobility and personal care. The care plan specified that the resident should be checked and provided incontinence care 2-4 times per shift and as needed, with peri-area cleaning after each episode, and repositioned every hour when in a chair. On the day in question, the resident was observed being placed in a wheelchair in the TV lobby after breakfast and remained in the same position until lunchtime, with no evidence of repositioning or toileting assistance during that period. Multiple staff members confirmed they had not assisted the resident with repositioning or toileting after breakfast. Documentation in the electronic health record indicated care was provided before breakfast, and staff statements conflicted regarding the timing of incontinence care. The facility's policy required hourly repositioning for residents in chairs, which was not followed in this instance.