Failure to Provide Timely Repositioning, Pressure Relief, and Incontinence Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards for repositioning, pressure relief, and incontinence care for two residents. One resident with spastic hemiplegia, limited mobility, and a history of skin integrity issues was observed sitting in a wheelchair for over seven hours without being repositioned or checked for incontinence. This resident was found with two incontinence briefs filled with feces overflowing onto their clothing and skin, and exhibited extremely reddened skin in the peri area and buttocks. Staff confirmed that the resident should have been checked and changed every two hours and that the use of two briefs was not in accordance with facility protocol. Another resident with Parkinson's disease and peripheral vascular disease, who was dependent for mobility and had existing wounds on the right buttock and hip, was observed sitting in a recliner without a pressure-relieving cushion for several hours. The care plan for this resident included the use of a pressure-relieving cushion and a turning and repositioning schedule, but these interventions were not implemented. Upon incontinence care, the resident was found to have an open area on the right buttock and redness on both buttocks. Interviews with staff, including a nursing assistant, LPN, DON, and regional clinical director, confirmed that residents unable to reposition themselves should be repositioned by staff, pressure-relieving devices should be in place, and incontinence care should be provided in a timely manner. The facility's own policies on repositioning, perineal care, and activities of daily living were not followed, resulting in the deficiencies observed for both residents.