Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for four residents who were dependent on staff for toileting and personal hygiene due to conditions such as cerebral infarction, hemiplegia, impaired mobility, and severe cognitive impairment. Multiple residents reported not being cleaned or changed for extended periods, with some stating they had not received care since early morning hours. Observations confirmed that residents remained wet or soiled for several hours, and staff did not consistently provide care in accordance with the residents' care plans and physician orders, which required frequent and thorough incontinent care to maintain skin integrity and prevent complications. Direct observations of care revealed that staff did not fully cleanse all affected areas during incontinence care. For example, staff were seen wiping only parts of the groin and buttocks, leaving stool or urine on the skin, and failing to dry the area or apply prescribed moisture barrier creams. In some cases, open sores and reddened skin were noted, and care was performed in a manner that caused further skin breakdown. Additionally, privacy measures were not always observed, as window blinds were left open during care, exposing residents to potential view from outside. Interviews with staff indicated inconsistent understanding and implementation of proper incontinent care procedures, including the frequency of checks and the thoroughness of cleaning. The facility's own policy required washing the entire perineal area and all areas affected by incontinence, but this was not consistently followed. The Director of Nursing confirmed the expectation for timely, complete care and privacy, which was not met in these instances.