Failure to Apply Ordered Incontinence Barrier Cream
Penalty
Summary
The facility failed to ensure that incontinence barrier cream was applied as ordered for one resident. The resident, who had diagnoses including major depressive disorder, dementia, COPD, and dysphagia, was frequently incontinent of bladder and occasionally incontinent of bowel, and required partial to moderate assistance with toileting. Physician orders specified that a house moisture barrier ointment should be applied to the perineum, buttocks, and coccyx after each incontinent episode and as needed. During an observation, a CNA provided incontinence care to the resident but did not apply the ordered barrier cream before replacing the incontinence brief and clothing. The CNA later confirmed in an interview that the cream was not applied. The DON also verified that the CNA did not follow the physician's order. Facility policy required the application of a protective or barrier ointment after each incontinent episode as part of standard incontinence care protocol.