Failure to Provide Appropriate Incontinent Care and Maintain Personal Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain good personal hygiene, specifically regarding appropriate incontinent care. Three residents were identified as not receiving proper care: one resident was observed wearing two saturated briefs at the same time, a practice known as double briefing, which is not permitted by facility policy. Two other residents reported having been double briefed in the past, although they could not recall specific dates or staff involved. Observations and interviews confirmed that double briefing had occurred, and one resident was found with redness to the buttocks during care. Medical records indicated that the affected residents had significant physical and cognitive impairments, including chronic respiratory failure, heart failure, diabetes, quadriplegia, dementia, and incontinence. Care plans for these residents included interventions such as regular checks for incontinence and prompt changing of disposable briefs. Despite these interventions, staff interviews revealed that double briefing had been practiced, sometimes at the direction of other staff members, and that staff were aware this was not acceptable due to the risk of skin breakdown and infection. Staff interviews further confirmed knowledge of the facility's expectations regarding incontinent care, with several CNAs and an LVN stating that double briefing was not allowed and could lead to skin integrity issues. Documentation showed that at least one CNA had received training indicating not to double brief residents. Facility policies reviewed emphasized the importance of cleanliness, comfort, and prevention of infection and skin irritation, but the observed and reported practices did not align with these standards.