Failure to Provide Timely and Appropriate Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for two residents who were dependent on staff for all activities of daily living. For one resident with diagnoses including senile degeneration of the brain, Parkinson's Disease, and paranoid schizophrenia, observations revealed the resident was wearing two incontinence briefs, both soaked with dark yellow urine and containing a moderate amount of hard brown feces. Staff noted the resident had not been changed in a while, and the resident cried out in pain during care, with visible redness on the inner buttocks. Additionally, one CNA failed to change soiled gloves or perform hand hygiene before applying a clean brief, contrary to facility policy. For another resident with dementia, anxiety disorder, and adult failure to thrive, staff observed a large amount of dark yellow urine in the incontinence brief, which appeared to have been present for some time. The resident was also found with a folded blanket and a reusable chux pad under the buttocks, with the blanket showing dried urine. Staff indicated these items were likely used for added protection against incontinence, but this was not in line with standard practice. During care, the resident was left uncovered from the waist down while a CNA left the room to gather supplies. Both incidents were observed to be inconsistent with the facility's incontinence care policy, which requires cleansing with perineal wash, proper glove use, hand hygiene, and changing linens and clothing as needed. The deficiencies were identified through observation, interview, and record review, and affected two out of three residents reviewed for incontinence care.