Incomplete and Untimely Incontinent Care Provided to Multiple Residents
Penalty
Summary
The facility failed to provide timely and complete incontinent care for three residents who required assistance with activities of daily living due to severe cognitive or physical impairments. One resident with chronic kidney disease, hypertension, and impaired mobility was observed with saturated clothing from urine and did not receive thorough perineal cleaning, as the groin and genital areas were not properly cleansed during care. Another resident, dependent on staff for toileting and always incontinent of bowel and bladder, experienced incomplete cleaning after an episode of incontinence, with only the buttocks and anal area wiped, and no attention given to the front side or soiled handrails after the resident touched them with feces-contaminated hands. A third resident, who was cognitively intact but fully dependent on staff for toileting and always incontinent, did not receive adequate perineal care after urinating on himself during a care episode. The staff cleansed the buttocks, rectal area, inner thighs, and scrotum, but failed to clean the scrotum again or the penile head after visible urine pooled on the scrotum. Staff interviews confirmed that if urine was noticed, further cleaning would have been performed, indicating a lack of thoroughness in the care provided. Facility policy for perineal care outlines specific steps for cleaning both male and female residents, including washing and rinsing all relevant areas and changing gloves when moving from dirty to clean areas. Observations and staff interviews revealed that these procedures were not consistently followed, resulting in incomplete perineal care for the residents involved.