Failure to Provide Timely Incontinence Care and Repositioning Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including transfers and incontinence care, was left in a geriatric chair for approximately nine hours without being changed or repositioned. The resident had significant medical conditions, including dysphagia, aphasia, tracheostomy status, chronic respiratory failure, muscle wasting, and was always incontinent of bowel and bladder. The care plan identified the resident as being at risk for pressure ulcers and required frequent turning, repositioning, and incontinence care, with interventions such as use of an alternating air mattress and pressure-reducing overlay. On the day of the incident, the occupational therapist transferred the resident from bed to a geriatric chair in the morning, confirming the brief was dry at that time. Video footage and documentation revealed that the resident remained in the chair from approximately 8:45 AM until around 6:00 PM, with no evidence of being transferred back to bed or having incontinence care provided during this period. Staff interviews confirmed that perineal care could not be performed while the resident was in the chair and that residents requiring mechanical lifts for transfers should not remain in a chair for extended periods without being repositioned or changed. Documentation logs and staff statements indicated gaps in care, with some staff unaware of the resident's status or assuming care had been provided by others. As a result of this lapse in care, the resident developed skin breakdown in the sacral area, as observed in photographs and confirmed by subsequent assessments. The resident's family raised concerns about the frequency of checks and new redness to the perineal area, leading to further review. The facility's own policies and staff interviews acknowledged that residents with similar needs should be checked and changed at least every two hours, and that prolonged periods in a chair without care could lead to skin integrity issues. The failure to provide timely incontinence care and repositioning directly contributed to the resident's skin breakdown.