Failure to Provide Timely Incontinence Care and Maintain Cleanliness
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and total dependence for toileting and showers did not receive timely incontinence care. The resident, who was always incontinent of bowel and bladder, was observed to have a strong odor of urine and stool coming from their room. Upon further observation, the resident's bed sheets were found to be saturated with urine and soiled with stool, and the resident was wearing an incontinence brief with an additional brief used as a pad inside. Staff interviews confirmed that the resident's incontinence care products were saturated from the overnight shift and that care had not been provided during the night. The certified nurse aide reported that the stool was stuck to the resident's skin and that the bed sheets had not been changed during the morning care. The facility's policy required perineal care to be provided as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. However, the care plan for the resident specified peri-care with each incontinence episode, and the Director of Nursing stated that briefs should be checked and changed every two hours. Despite these requirements, the resident did not receive timely incontinence care, and multiple incontinence products were used in a manner not consistent with standard practice. This failure affected one resident directly and had the potential to impact other residents identified as incontinent.