Resident Left in Wet Brief for Extended Period Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident with severe dementia and urinary incontinence was left in a wet brief for an extended period, resulting in a rash and excoriation to the groin area. The resident was unable to communicate her needs and relied on staff for incontinence care. On the evening in question, the assigned CNA failed to perform the required two-hour checks and did not change the resident's brief for approximately eight hours. When oncoming staff arrived, they found the resident saturated with dried and wet urine up to her shoulders, and the nurse confirmed the resident's condition and documented skin breakdown. Multiple staff interviews revealed that the CNA assigned to the resident gave conflicting accounts of when care was last provided, initially claiming to have changed the resident multiple times, then admitting she had not done so since the afternoon. The CNA also blocked other staff from entering the resident's room and yelled at a coworker who confronted her about the lack of care. Other CNAs and nurses stated that routine practice was to check and change residents at least every two hours, and that leaving a resident in a wet brief could quickly lead to skin breakdown or infection. The facility's policy required regular incontinence care and monitoring to prevent neglect and harm. Staff interviews confirmed that the resident never refused care and that there were standing orders for frequent checks due to her incontinence and cognitive impairment. The failure to provide timely incontinence care directly resulted in physical harm to the resident, as evidenced by the documented skin issues and the observations of multiple staff members.