Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A deficiency occurred when staff failed to provide timely perineal care and repositioning for a resident with severe cognitive impairment, stroke, dementia, and depression. The resident was observed to have been left in a saturated brief containing stool and soaked clothing, with the last change reportedly occurring early in the morning. Certified Nursing Assistants (CNAs) admitted the resident had been overlooked due to being asked to assist with other residents, and were unsure of the exact time the resident was last changed. The resident was dependent on staff for all activities of daily living and was always incontinent of bladder and frequently incontinent of bowel, as documented in the Minimum Data Set (MDS) and care plan. Facility policy and the resident's care plan required that incontinent residents be checked and changed at least every two hours, and that staff monitor for signs of infection and skin breakdown. The care plan also directed frequent hourly rounds while the resident was in a wheelchair. Interviews with nursing staff, including the RN, treatment nurse, DON, and administrator, confirmed that staff were expected to check and change residents every two hours, especially those with incontinence, to maintain skin integrity and prevent infection. Despite these policies and staff training, the resident was not checked or changed as required, resulting in prolonged exposure to urine and feces. The incident was directly observed by the surveyor, and staff interviews confirmed a lapse in following established protocols for incontinence care and repositioning. Facility documents and in-service records showed that the involved CNAs had been educated on these requirements prior to the incident.