Failure to Provide Timely Repositioning and Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain activities of daily living (ADL) for two dependent residents. One resident, under 65 years old with diagnoses including traumatic brain injury, post-traumatic seizures, and chronic respiratory failure, was observed sitting in a geri chair in the dining room for nearly two hours without repositioning or incontinence care. Despite expressing discomfort and requesting assistance, staff did not respond promptly, and the resident remained in a saturated urine brief until a CNA arrived and provided care. Documentation and interviews confirmed that incontinence care was not provided as frequently as required by the resident's care plan, which specified perineal care after each incontinent episode and frequent checks. Another resident, over 65 years old with Huntington's disease, dementia, and other behavioral and movement disorders, was observed sitting in a wheelchair at a dining room table for over two and a half hours without being repositioned or offered repositioning. The resident's care plan indicated a need for assistance with repositioning, but staff interviews revealed a belief that the resident could offload her own weight and move herself if needed. However, observations contradicted this, as the resident remained in the same position for an extended period. These failures were documented through direct observation, record review, and staff and resident interviews. The deficiencies involved not adhering to care plans and established protocols for timely repositioning and incontinence care, resulting in prolonged periods without necessary assistance for both residents.