Failure to Provide Timely Incontinent Care and Maintain Personal Hygiene
Penalty
Summary
A deficiency occurred when a female resident with severe cognitive impairment, multiple medical diagnoses including dementia, muscle weakness, and a history of incontinence, did not receive timely incontinent care. The resident required extensive assistance with activities of daily living (ADLs), including toileting, personal hygiene, and bed mobility, as documented in her care plan. Despite these needs, the resident was left in a soiled brief and saturated linens for more than four hours, resulting in a rash on her buttocks and thighs, and feces present in the vaginal and inner thigh areas. The incident was discovered when the resident's family member arrived and found her in this condition, noting that she had not received a scheduled bath or a change of briefs until later that day. Staff interviews confirmed that the resident was found with a soaked and soiled brief at the start of a CNA's shift, and that the family member witnessed the resident being changed. Another CNA reported that the resident's wheelchair and dress were also soiled with bowel, and that the family member had requested more frequent changes due to diarrhea. The charge nurse was unaware of the resident's condition and could not verify if the resident had been bathed as scheduled. Facility policy required staff to check incontinent residents at least every two hours and provide perineal care to maintain cleanliness and comfort, prevent infection, and observe skin condition. However, staff interviews and documentation indicated that these procedures were not followed, resulting in the resident remaining in a soiled state for an extended period.