Failure to Provide Timely Incontinence Care and Maintain Proper Infection Control
Penalty
Summary
A resident with Alzheimer's disease, anxiety disorder, and type 2 diabetes mellitus was identified as being incontinent of bowel and bladder, requiring substantial to maximal assistance for toileting hygiene and other activities of daily living. The resident's care plan specified that incontinence care should be provided every two hours and as needed, including the application of barrier cream after each episode. On the day in question, there was no documentation in the progress notes or aide charting indicating that the resident's incontinence brief had been changed from 7:00 A.M. through 2:26 P.M., nor was there evidence that the resident refused care during this period. At 2:26 P.M., a CNA was observed providing incontinence care to the resident, whose brief was found to be saturated with urine and contained a moderate-sized, formed bowel movement. The resident's draw sheet and underlying sheet were also saturated with urine, with dried yellow urine visible. The CNA acknowledged that the resident appeared not to have been changed for a significant amount of time and confirmed that a blanket had been improperly used as a draw sheet. During care, the CNA placed soiled linens on the floor instead of directly into a plastic bag and failed to apply barrier cream before putting on a new brief. The DON later confirmed that these actions were not in accordance with facility policy and that incontinence care should have been provided in a timely manner.