Failure to Provide Timely Repositioning, Incontinence Care, and Dignity for a Dependent Resident
Penalty
Summary
A resident with moderate to mild cognitive impairment, anxiety, mood disturbance, and dementia was admitted with a care plan requiring frequent turning, repositioning every two hours, and incontinence checks due to a moderate risk for skin breakdown. The resident was also to be assisted with activities of daily living (ADLs), including dressing and maintaining dignity. On the day of observation, the resident was found lying in bed in only a brief, with the door wide open, and was not covered by clothing or a blanket. Multiple staff members, including nursing assistants and a registered nurse, walked past the resident's room over a period of more than an hour without providing care or addressing the resident's exposure or needs. The resident was not assisted with repositioning, incontinence care, or dressing during the morning shift, despite being dependent on staff for these ADLs. When a hospice nursing assistant entered the room, the resident's brief was found to be saturated with urine and feces, and the bed sheets were also soaked. Interviews with staff confirmed that the resident had not received any care that morning, and the director of nursing acknowledged that such inaction increases the risk for skin breakdown. Facility policies required staff to follow individualized care plans for incontinence and repositioning, as well as to maintain resident dignity, but these were not followed in this instance.