Failure to Provide Timely and Adequate Incontinence Care Resulting in MASD
Penalty
Summary
A resident who was occasionally incontinent of bladder and always incontinent of bowel did not receive timely and appropriate incontinence care, resulting in the development of Moisture Associated Skin Damage (MASD) on both buttocks. The resident reported waiting 45 minutes for his call light to be answered during the midnight shift, observing a CNA walking in the hallway and ignoring his request. When care was finally provided, the CNA did not adequately wipe or dry the resident, and the resident had to request a change of a soaked bed pad. During assessment, the resident verbalized pain when the reddened area was touched, and the wound care nurse confirmed the presence of MASD due to moist skin. Further review revealed that the CNA who provided care at 9:10 AM had not previously attended to the resident since starting her shift at 6:00 AM. The LPN on duty was unaware of the skin issue, and there was no communication from the previous shift regarding the resident's condition. The resident's care plan indicated a need for substantial assistance with toileting hygiene, and the Braden Scale identified the resident as at risk for pressure ulcers. Facility policy required staff to thoroughly rinse and pat dry the area after incontinence care, but this procedure was not followed, contributing to the skin breakdown.