Failure to Provide Timely Incontinence and ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for all activities of daily living (ADL) and incontinence care was found in a severely soiled condition. Staff interviews and observations revealed that the resident was left in bed with a soiled gown, red and irritated scrotum, inner thighs, and buttocks, and bed linens soaked with urine and feces. The resident was also noted to have dried and new emesis on his gown and bed, with a strong odor of emesis, feces, and urine present in the room. The responsible CNA for the night shift had left the facility before being instructed to provide care, and the day shift CNA was asked to clean the resident prior to hospital transfer. However, the resident remained in a soiled state until the day shift staff intervened. The resident had a complex medical history, including respiratory failure, hemiplegia, tracheostomy, gastrostomy, and dysphagia, and was unable to communicate needs, making him fully reliant on staff for care. The care plan required total assistance with bed mobility, transfers, all ADLs, and incontinence care, including peri-care after each incontinent episode and monitoring for skin excoriation. Despite these requirements and facility policy mandating perineal care to maintain skin integrity, staff failed to provide timely and adequate care, resulting in the resident being left in unsanitary and potentially harmful conditions.