Failure to Provide Incontinence Care Results in Moisture-Associated Skin Damage
Penalty
Summary
Staff failed to provide care in accordance with a resident's comprehensive person-centered care plan and the resident's expressed preferences, resulting in the development of three new areas of moisture-associated skin damage. The resident, who was at risk for pressure ulcers and dependent on staff for toileting and incontinence care, reported that over a weekend, CNAs did not consistently perform check and changes as needed. The resident stated that staff complained about the time and effort required to use a Hoyer lift for brief changes and left her in a wet brief overnight. Another resident corroborated that staff refused to change the resident's brief, citing it was only damp and that using the Hoyer lift was too much work. Review of the resident's records showed that prior to the incident, there was no skin breakdown on her medial thighs or intergluteal cleft. However, following the period of inadequate care, three new areas of incontinence-associated dermatitis were documented, all described as painful and burning by the resident. The care plan required thorough skin care after incontinent episodes and the use of barrier cream, as well as assistance with toileting upon request. Despite these interventions being in place, staff did not follow the care plan, leading to the resident acquiring new wounds.