Failure to Provide Properly Sized Incontinence Supplies and Assess MASD
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriately sized incontinence products and to comprehensively assess moisture-associated skin damage (MASD) for a resident. The resident was admitted with multiple diagnoses, including COPD, rheumatoid arthritis, CHF, atrial flutter, spinal stenosis, and insomnia, and had no skin issues on admission. An admission Braden Scale identified the resident as high risk for pressure ulcer development, and the admission MDS documented intact cognition, frequent bladder incontinence, no skin concerns, and a weight of 219 pounds. The care plan identified risk for skin breakdown related to incontinence, age-related changes, and impaired mobility, with interventions to notify nursing and providers of any skin abnormalities and to monitor skin daily during care. Subsequent documentation showed that a weekly skin assessment noted the resident as "red" on a specified date in December, but there was no further description of the redness. A physician’s order was then obtained to cleanse the bilateral buttocks/sacrum and apply stoma powder followed by A&D ointment every shift and as needed for MASD. However, the medical record contained no comprehensive skin assessment of the MASD, and nurse’s notes from the days surrounding the onset of MASD did not document the condition. The LPN responsible for wound rounds later stated she was unaware the resident had MASD and confirmed that, if present, it should have been assessed and documented per facility practice and policy. Interviews and observations revealed systemic issues with incontinence supply management that contributed to the deficiency. Multiple nurses reported the facility frequently ran out of larger-sized briefs and that staff sometimes used smaller briefs or doubled briefs when appropriate sizes were unavailable. One nurse confirmed the resident became excoriated from briefs being too tight. The resident reported that her usual size briefs ran out, she was placed in smaller briefs with an additional medium brief inside, and she developed excoriation on her bottom and groin from the brief rubbing. Central supply staff reported not having a list of residents’ brief sizes, ordering supplies based only on prior week usage, and lacking a system to determine how many of each size to order, which was corroborated by the absence of facility documentation showing such a system. Facility policies on skin care, wound care, and requisitioning daily supplies required monitoring for skin changes and maintaining adequate supplies, but the practices described did not align with these requirements.
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