Failure to Provide Timely Incontinence Care Resulting in Skin Breakdown
Penalty
Summary
A male resident with severe cognitive impairment, total dependence for activities of daily living, and a history of dementia, anemia, acute kidney failure, benign prostatic hyperplasia, and cerebral infarction, was not provided with appropriate incontinence and perineal care as required by facility policy. The resident was observed sitting in a dining area for several hours without being checked or changed, despite being always incontinent of urine and frequently incontinent of bowel. Certified Nurse Aides (CNAs) attempted but failed to transfer the resident to the toilet and did not check or change his brief before returning him to the dining area. When questioned, staff reported the last change occurred early in the morning, several hours prior to the observation. Later in the day, the resident was finally checked and changed in bed, at which time his brief was found to be completely soaked with urine and feces, and a lesion was observed on the scrotal area. The resident’s family member reported that the resident was often found wet with double briefs during visits and had previously notified staff about the wound. Wound care staff and nurse practitioners confirmed the presence of moisture-associated skin damage (MASD) or incontinence-associated dermatitis (IAD) on the scrotum, attributed to repeated exposure to body fluids and inadequate incontinence care. Facility policy requires residents to be checked and changed at least every two hours, with perineal care provided as needed to maintain cleanliness and prevent skin irritation. Interviews with nursing staff and review of the care plan confirmed that these protocols were not followed for this resident, resulting in the development of IAD. Documentation and staff statements indicated that the resident was not checked or changed according to policy, leading to prolonged exposure to moisture and subsequent skin breakdown.