Inappropriate Double-Bruiefing of Dependent Resident During Incontinence Care
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including incontinence care, was found to be wearing two incontinence briefs at the same time. During incontinence rounds, an LPN/Unit Manager observed that the resident's incontinence brief appeared layered, and upon further inspection, it was confirmed that there was a second, dry incontinence brief inside the outer brief. The LPN/Unit Manager acknowledged that this was not appropriate care and indicated that a nursing aide from hospice care likely applied the briefs in this manner. The resident involved had a history of hemiplegia and hemiparesis following a stroke, aphasia, and severely impaired cognition, as indicated by a BIMS score of 2 out of 15. The resident was always incontinent of bowel and frequently incontinent of bladder, and was totally dependent on staff for personal hygiene, as documented in the care plan. Facility policy required that residents who are incontinent receive appropriate treatment to prevent infections and restore continence to the extent possible. The observed practice of double-briefing did not align with this policy.