Delay in Providing Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living, including personal hygiene and incontinence care, was left soiled for approximately 20 minutes before being cleaned. The resident had a history of muscle weakness, hemiplegia, hemiparesis, and was at risk for skin breakdown, as documented in the care plan and medical records. Orders were in place for frequent skin assessments and specialized equipment, such as a low air loss mattress, due to an existing stage 3 pressure injury. On the day of the incident, staff were aware that the resident had soiled himself. The treatment nurse acknowledged the need for assistance but was waiting for help. A CNA entered the resident's room but left without providing care, stating he was looking for someone to assist him. The CNA was later observed assisting another resident before returning with a second CNA to clean the original resident. This resulted in a delay of about 20 minutes from the time staff were notified of the need for care to when the resident was actually cleaned. Interviews with staff, including the DON, confirmed that the delay was not in accordance with facility policy, which requires prompt cleaning to maintain hygiene and prevent infection or skin breakdown. Facility policies reviewed emphasized the importance of timely perineal care and assistance with ADLs for residents unable to perform these tasks independently.