Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for toileting and incontinent care reported being left in a soiled brief for four hours, despite activating her call light at 10:00 a.m. and not being changed until 2:00 p.m. The resident stated that her brief was wet with urine and contained a bowel movement during this period, and her roommate confirmed witnessing the incident. The resident reported the delay to both an LPN and a CNA, as well as other nursing staff. She also indicated that she had a clock in her room and timed the incident, and that her skin became raw as a result of prolonged exposure to the soiled brief. On a subsequent observation, the resident was again found with a soaked brief that had leaked through her clothing, and her buttocks were noted to be pink, shiny, and raw. The resident's medical record indicated diagnoses including urinary tract infection, multiple sclerosis, chronic kidney disease, morbid obesity, and neuromuscular dysfunction of the bladder, with a care plan requiring assistance with ADLs and incontinent care as needed. A recent skin assessment documented moisture-associated dermatitis, and a physician order was in place for application of a barrier cream to the buttocks every shift for redness. Facility policy and staff competency requirements included providing toileting or perineal care as needed.