Failure to Provide Timely Incontinence Care Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and total dependence for toileting hygiene did not receive timely assistance with incontinence care. Documentation showed that after receiving toileting assistance in the late morning, the next documented care was not provided until the evening, resulting in a gap of approximately 6.5 hours. During this period, the resident remained in a wet brief, and both the resident and a family member reported that requests for assistance were not answered. The family member observed the resident in a wet brief for several hours and reported that staff did not respond to the call light or provide care during this time. The resident had a history of heart failure, diabetes, and acute embolism, and was assessed as lacking capacity to make decisions. Care plans indicated the resident was at risk for skin breakdown and required frequent incontinence care and skin protection measures, including the use of topical ointment for moisture-associated skin damage (MASD) at the coccyx. Despite these interventions being documented, the resident developed MASD with superficial skin breakdown and bleeding, as confirmed by staff and family observations. The wound was first noted by a CNA and later reported to the wound care nurse by the family member. Interviews with staff confirmed the importance of frequent brief changes for this resident due to frequent episodes of incontinence, including loose stools. Facility policy required routine checks and assistance with hygiene and elimination for residents unable to perform activities of daily living independently. However, the lack of timely incontinence care and failure to respond to requests for assistance directly contributed to the resident's skin breakdown and discomfort.