State Findings:
Specifically, the facility failed to provide repositioning and incontinence care according to professional standards of practice for Resident #22 and Resident #5. Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Resident #22: Based on the observations, the resident was not provided repositioning or incontinence care from 7:00 a.m. until 1:22 p.m. for a total of six hours and twenty minutes.
LPN #1 was interviewed on 5/5/22 at 1:14 p.m. She said the resident was provided incontinence care every couple of hours by the CNAs. She said each resident had a repositioning schedule but she did not have access to that schedule.
CNA #4 was interviewed on 5/5/22 at 2:05 p.m. CNA #4 said that she got the resident up a little after 7:00 a.m. She said that she had not provided any care for the resident after getting her up at 7:00 a.m. that day.
Resident #5 : The resident had not been offered personal care or repositioning assistance for approximately five hours since the beginning of the observation period.
Certified nursing assistant (CNA) #4 was interviewed on 5/5/22 at 1:31 p.m. She said she was the only certified nursing assistant working the hallway at the moment because the other certified nursing assistant was out of the building at an appointment with another resident. She said the resident should be checked and changed for toileting after breakfast and after lunch. She said she should lay down after lunch to change her positioning, however she was a fall risk and it made her nervous to leave her in her bed for long periods of time. She said she had not been out of her wheelchair or had her briefs changed for approximately five hours. She said that was too long for her to go without toilet assistance. She said her briefs were wet and soiled.
The director of nursing (DON) was interviewed on 5/10/22 at 10:13 a.m. She said Resident #5 and Resident #22 were at risk for pressure ulcers and skin breakdown. She said residents who were at risk for pressure ulcers and skin breakdown should be offered repositioning and toileting every two to three hours.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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