Failure to Provide Repositioning and Toileting per Care Plan
Penalty
Summary
The facility failed to provide necessary care and services consistent with a resident's assessed needs and care plan, specifically regarding repositioning, toileting, and pressure ulcer prevention. Multiple observations over several days showed that the resident remained lying flat on her back with her left lower extremity elevated on pillows, and there was no evidence of regular repositioning or side-to-side turning as required by her care plan. Staff interviews revealed inconsistent knowledge and implementation of the facility's policies for turning, repositioning, and check-and-change routines, with several staff members unable to confirm that these tasks were being performed every two hours as directed. Review of documentation for the period in question showed significant gaps in the frequency of repositioning and toileting/check-and-change activities. Records indicated that the resident was repositioned only once or twice in a 24-hour period on most days, with one day showing no repositioning at all. Similarly, documentation of toileting and check-and-change activities revealed that these were performed only once or twice per day, and on some occasions, not at all within a 24-hour period, despite the care plan's directive for these interventions to occur every two hours. Interviews with staff further confirmed that the facility's expectations for care were not consistently met in practice. Some staff members acknowledged that the two-hour schedule for turning, repositioning, and check-and-change was not always followed, and there was confusion or lack of awareness regarding the specific requirements in the resident's care plan. Policy review indicated that assistance with activities of daily living, including bed mobility and toileting, was to be provided as directed in the care plan and regularly documented, but this was not reflected in the actual care provided or in the documentation reviewed.