Failure to Provide Incontinence Care and Showers Resulting in Skin Breakdown
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADL), including incontinence care and showers, did not receive regular and adequate care as required by their care plan. The resident, who had a history of hemiplegia, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension, was cognitively intact and reported being left in urine and feces for extended periods. The resident and their family repeatedly informed staff and administration about the lack of timely incontinence care and showers, with the resident experiencing significant pain and the development of open areas on the skin. Documentation and interviews confirmed that there were multiple shifts with no record of incontinence care or showers being provided, and the resident went at least 13 days without a shower. Direct observation by surveyors and staff revealed the resident had multiple open areas with serosanguinous drainage on the buttocks and thighs, consistent with moisture-associated skin damage (MASD). During a skin assessment, feces was observed between the resident's buttocks even after staff claimed to have provided peri-care. Staff, including the DON and LPNs, acknowledged that proper incontinence care was not consistently documented or provided, and that the standard of care requires residents to be checked and changed every two hours to prevent skin breakdown. The wound care nurse and restorative nurse confirmed that the lack of documentation indicated care was not provided, and that the resident's skin was wet and wrinkled during assessment, further supporting the finding of inadequate care. The facility's own policies required staff to observe skin during direct care, provide peri-care after each incontinence episode, and document any skin irritation or breakdown. Despite these requirements, there was no evidence that the resident received the necessary care, and staff failed to report or treat the skin breakdown in a timely manner. The medical director and other staff affirmed that the observed skin breakdown and presence of feces were clear signs that incontinence care was not being provided as required.