Failure to Provide Timely and Complete Incontinence Care
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical diagnoses, including dementia, psychotic disturbance, and dysphagia, did not receive timely and complete incontinence care. Observation revealed that two CNAs failed to maintain a clean field for cleansing supplies, placed an open incontinence brief directly on the resident's personal pillow, and did not cleanse the resident's front perineal area. The resident's incontinence brief was found fully saturated with urine and feces, and dried feces were present on the resident's buttock. One CNA admitted to not washing the front perineal area during care, and there was a significant gap in care provision since the CNA's arrival earlier that day. Interviews with staff confirmed that complete incontinence care, as outlined in the facility's policy, was not provided. The Director of Nursing acknowledged that the resident is vulnerable to skin breakdown due to low cognition and emphasized the importance of following the care plan, which includes thorough cleansing of the perineal and perianal areas. The facility's policy specifies the correct procedure for perineal cleansing, which was not followed during the observed care.