Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. One resident with severe cognitive impairment and multiple diagnoses, including schizophrenia and diabetes, was observed lying in bed for several hours in saturated sheets with urine and feces. Despite staff entering the room multiple times, the resident was not cleaned or checked for incontinence, and the door was repeatedly closed without intervention. The resident confirmed not being cleaned or checked during this period, and staff acknowledged not having time to provide care due to staffing issues. When incontinent care was eventually provided, staff failed to follow proper infection control and hygiene protocols. Hand hygiene was not performed before or after glove changes, and soiled gloves were used to handle clean supplies. The resident's peri-care was incomplete, as the penis and testicles were not cleaned, and soiled clothing was not promptly removed. The process lacked the use of a gait belt for safe transfer, and contaminated gloves were used to search for clean clothing, further breaching infection control standards. A second resident, cognitively intact but dependent on staff for toileting, also received incomplete peri-care. During observed care, staff failed to retract the foreskin to clean the entire penis and did not dry the resident after cleaning. The facility's own policies require residents to be checked for incontinence at least every two hours and for complete peri-care to be provided, including proper hand hygiene and cleaning techniques. Interviews with staff and the DON confirmed expectations for timely and thorough care, which were not met in these instances.