Failure to Maintain Resident Dignity and Adhere to Incontinence Care Policy
Penalty
Summary
A certified nursing assistant (CNA) placed two incontinence briefs on a female resident with severe dementia, chronic kidney disease stage 4, and a history of urinary tract infections. The resident required partial to moderate assistance with toileting hygiene and was always incontinent of urine and bowel. The CNA stated that the resident was combative and that the second brief was used to prevent the resident from urinating through the first brief before she could be changed again. The CNA also indicated that she believed it would be less of a struggle to change the resident later if two briefs were used. Another staff member, a hospitality aide, denied assisting with care and stated she only performed non-care tasks. Interviews with other staff, including licensed vocational nurses (LVNs) and assistant directors of nursing (ADONs), confirmed that facility policy and staff education prohibit the use of more than one brief at a time, citing risks to skin integrity and resident dignity. The ADONs and administrator stated that staff are regularly trained and checked off on peri-care and that double briefing is not allowed. However, the CNA involved admitted to the practice, and the family member of the resident reported this was not the first occurrence, expressing concern due to the resident's medical history. Facility records, including care plans and in-service training documentation, reflected that staff were instructed to maintain skin health, prevent infections, and provide care in a manner that supports resident dignity. Despite these policies and training, the incident occurred, and the resident was found with two briefs, which was not in accordance with facility policy or the resident's care plan. The resident was not able to be interviewed due to cognitive impairment, but was observed to be clean and free of odors at the time of surveyor observation.