Failure to Provide Timely and Proper Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed during a survey. For one resident, a wound care nurse and CNA were observed repositioning the resident, revealing a disposable brief soaked with urine that had leaked onto the underlying cloth pad. The CNA provided incontinence care but did not change gloves after cleaning the peri-anal and sacral areas, then applied a clean brief with the same gloves. The CNA assigned to this resident and another dependent resident confirmed that he had not provided incontinence or morning care to either resident by the time of the observation. The care plans for both residents indicated the need for assistance with ADLs and incontinence care due to significant medical conditions, including neurological deficits, contractures, and incontinence. A second resident was also found soaked with urine and fecal matter on the brief and rectal area. The same CNA provided incontinence care without changing gloves between cleaning soiled areas and applying a clean brief. When informed of this, the CNA changed gloves but did not perform hand hygiene before donning new gloves. The facility was unable to provide a policy specific to ADL and incontinence care procedures, though a general policy required resident checks at least every two hours. These observations demonstrate a failure to provide timely and appropriate incontinence care and to follow proper infection control practices.