Failure to Provide Timely and Policy-Compliant Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate incontinence care in accordance with its policy for a resident who was always incontinent of bowel and bladder. The resident, admitted with diagnoses including Lewy body dementia, hypertension, anxiety, muscle weakness, and abnormal posture, had an MDS indicating cognitive impairment and continuous incontinence. The resident’s care plan included an intervention for incontinence care every two hours and as needed, and the facility’s perineal care policy stated that perineal care would be provided to promote cleanliness, prevent infection, and prevent skin breakdown. Review of the physician’s orders showed there was no order for brief liners. During an observation of incontinence care, surveyors noted the resident appeared to have a dry brief, but further inspection revealed the resident was wearing two briefs, one on top of the other, with the brief next to the skin saturated with urine. The CNA providing care reported she had been performing every two-hour brief checks since the start of her shift by checking only the outer brief and was unaware that a second brief was in place. She acknowledged that facility policy prohibited double briefing and that brief liners could only be used with a physician’s order. The DON confirmed that double briefing was not permitted, that brief liners required a physician’s order, and that this resident did not have such an order, demonstrating that the resident did not receive incontinence care consistent with facility policy.
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