Failure to Provide Adequate Incontinence and Skin Care
Penalty
Summary
A resident with a history of stroke, muscle weakness, and dementia was found to be incontinent of bowel and bladder and fully dependent on staff for toileting. The resident's care plan included interventions for incontinence care and the application of a skin barrier ointment after incontinence episodes to prevent skin breakdown. Physician orders specified cleansing the buttocks with soap and water and applying a thick zinc barrier every shift and as needed. During an observation of incontinence care, a large amount of dried stool was found in the crease of the resident's buttocks, and the bed linens were heavily soiled with dried urine and other debris, accompanied by a strong odor of urine. The certified nursing assistant (CNA) responsible for the resident reported having provided incontinence care approximately one hour prior to the observation. However, the CNA confirmed that she had not applied the required barrier cream after the last care episode and had not noticed the soiled linens at that time. There was no evidence of barrier cream residue on the resident during the observation, despite the resident being at risk for skin breakdown and having a care plan and physician order for its use. Facility policy required thorough cleansing of the rectal area and application of a moisture barrier if care planned, but these steps were not followed, resulting in inadequate incontinence care for the resident.