Failure to Provide Timely Incontinence Care Resulting in Prolonged Exposure and Skin Redness
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident with severe cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living. The resident was incontinent of bowel and bladder, at risk for pressure ulcer development, and required regular checks and care as outlined in the care plan. However, the care plan did not specify a time frame for incontinence checks. Staff interviews and observations revealed that the resident was last checked for incontinence and repositioned at 5:00 A.M., and subsequent staff were unaware of when the resident was last checked or changed. At approximately 10:15 A.M., a CNA attempted to provide care but was unable to do so due to the resident's combativeness and did not notify the nurse of the refusal or inability to provide care. Later, when care was finally provided, the resident was found to be heavily soiled with urine, which had soaked through the brief, blanket, and mattress sheet onto the mattress surface. The resident's buttock was also observed to be reddened, a change from a previous assessment. The lack of timely incontinence care and communication among staff led to prolonged exposure to urine and the development of skin redness. Facility policy required staff to check and clean residents after each incontinence episode, but this was not consistently followed, resulting in the deficiency.