Failure to Provide Timely Incontinence Care and Improper Use of Double Briefs
Penalty
Summary
The facility failed to provide timely incontinence care and improperly used double incontinence briefs for residents dependent on staff for ADLs. One resident reported not receiving incontinence care since getting out of bed in the morning and was found wearing two incontinence briefs, with a small amount of thick feces and blood in the brief. His buttocks, sacrum, scrotum, and left abdominal fold were excoriated, with the abdominal fold bleeding. The CNA caring for him stated she usually placed two briefs on him because she was unable to get to him promptly due to having many residents to care for, and that she checked residents every two hours and used the extra brief as a liner to keep his clothes dry. She reported he had last been changed at about 7:30 AM and acknowledged he had excoriation from sitting in a wet brief all day. The resident’s care plan documented a stage 2 pressure sore on the left buttock and risk for additional or worsening skin integrity issues related to incontinence, impaired mobility, diabetes, and comorbidities, with interventions including checking for incontinence as needed and providing peri care. Another resident was observed receiving incontinence care while wearing two incontinence briefs, with the brief saturated with urine and stool and his scrotum large and reddened. The CNA providing care stated the double briefs had been applied by the previous shift and acknowledged residents should not have two disposable briefs on at the same time because it was bad for their skin. This resident’s care plan indicated bowel and bladder incontinence with an intervention to clean the peri area with each incontinence episode. Resident council meeting minutes over several months documented resident concerns about call light response times, variability in staff follow-up, and staff turning off call lights before providing requested assistance. The DON stated residents should not have two incontinence briefs on unless this was a care-planned preference and acknowledged that double briefs may lead to skin breakdown and UTIs if not changed, and that incontinent residents were to be checked every two hours and as needed per facility policy, which required periodic checks and perineal/genital care to prevent infection and improve quality of care.
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