Failure to Provide Timely Incontinence and Perineal Care for Resident with Nephrostomy Tube
Penalty
Summary
A resident with chronic urinary tract infections (UTIs), a nephrostomy tube, and a history of breast cancer with metastasis was not provided with appropriate and timely incontinence and perineal care. Observations revealed that the resident was left in bed with soiled linens and a saturated brief for several hours after requesting assistance, resulting in visible distress and discomfort. The resident reported using the call light at 8:00 a.m. to be changed, but staff did not respond until after 12:22 p.m., at which time the resident was found tearful and in pain. The room had a strong ammonia odor, and the resident's nephrostomy tube dressing was observed to be several days old. Review of the resident's medical record indicated that she was incontinent two to three times daily throughout the month, but documentation showed that incontinence care was only provided two to three times per day, rather than the every two hours as required by facility policy and the resident's care plan. The care plan specifically called for assistance with incontinence care and for staff to check and change the resident every two hours and as needed. There was no documentation of the resident refusing care or exhibiting behaviors that would prevent staff from providing timely incontinence care. Interviews with facility staff revealed confusion and inconsistency regarding the resident's nephrostomy tube orders and care. The DON and Unit Manager provided conflicting information about the status and care requirements for the nephrostomy tube, and there was a lack of clarity about whether the tube was dislodged or functioning. The facility's policy required residents who are totally incontinent to be checked and changed every two hours, but this was not consistently followed for this resident.