Failure to Maintain Perineal Skin Integrity in Dependent Resident
Penalty
Summary
A resident with a history of left above-the-knee amputation, stage 2 pressure ulcer, type 2 diabetes mellitus, and schizophrenia was admitted to the facility and assessed as always incontinent of bladder and bowel, requiring substantial to maximal assistance for activities of daily living, including toileting and personal hygiene. The resident was identified as being at risk for skin injuries, with a care plan in place to keep the skin clean and dry, conduct frequent visual checks, and reposition the resident regularly. Despite these interventions, staff interviews and observations revealed that the resident received perineal care only twice during an 8-hour shift and developed redness, weeping, and excoriation in the perineal area. The resident reported pain during perineal care, and a treatment nurse confirmed the presence of Moisture-Associated Skin Damage (MASD) and dermatitis, with a denuded line and watery exudate below the coccyx, attributed to prolonged exposure to urine and feces due to incontinence. Review of facility policy indicated that exposure to urine and feces increases the risk of skin breakdown, especially in residents with impaired mobility and other comorbidities. The policy required evaluation of resident-specific risk factors and implementation of interventions to prevent skin damage. However, the findings showed that the resident's skin was not maintained in a clean and intact condition, and monitoring for incontinence was insufficient, as the resident should have been checked every two hours. This failure resulted in the development of MASD and discomfort for the resident.