Incomplete Incontinence Care Provided to Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide complete incontinence care to a male resident with severe cognitive impairment, dementia, and multiple other diagnoses, including muscle wasting, hypertension, and anemia. The resident was frequently incontinent of urine and occasionally incontinent of bowel, with a care plan specifying incontinence care at least every two hours and cleaning of the perineal area with each episode. During an observed care episode, the CNA removed the resident's soiled brief and cleaned the suprapubic, groin, and genital areas, but did not clean the resident's buttock area before applying a new brief. The CNA later acknowledged forgetting to clean the buttock area due to nervousness, despite having received peri-care training and passing a skill checkoff earlier in the year. The Assistant Director of Nursing (ADON), who was acting as the Director of Nursing (DON) at the time, confirmed that the buttock area should have been cleaned to prevent possible infection. Facility policy also required cleansing of the entire buttock area during incontinence care. This lapse in care was identified through observation, interviews, and record review.