Failure to Provide Timely Brief Changes and Daily Care
Penalty
Summary
The facility failed to provide adequate daily care, specifically timely brief changes, for two of three residents reviewed for care needs. One resident, who was dependent on staff for toileting and dressing due to conditions such as Parkinsonism and acute respiratory failure, had no documentation of assistance with toileting or brief changes during an entire evening shift. The Interim Director of Nursing confirmed that the resident's brief should have been changed during that time. Another resident, who had moisture-associated skin damage and was care planned for frequent brief checks and changes every two hours, was documented as having her brief changed only one or two times per 24 hours over multiple days. Skin assessments revealed the development of a stage 2 pressure ulcer and ongoing redness in the groin area. Interviews with the resident's son, CNAs, and RNs confirmed that the resident was not changed as frequently as required, and that this lack of care contributed to skin breakdown.