Failure to Provide Timely Incontinence and ADL Care Resulting in Prolonged Soiling
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance, including timely incontinence care, grooming, and hygiene, to a male resident with severe cognitive impairment and total bowel and bladder incontinence. The resident had dementia, convulsions, COPD, and was on hospice with a terminal prognosis and adult failure to thrive. His care plan documented an ADL self-care performance deficit and required staff assistance for bathing, bed mobility, dressing, toilet use, and incontinence care every two hours. On the morning in question, multiple staff members observed the resident with significant soiling and poor hygiene. The RN Treatment Nurse, called to the room around late morning due to skin concerns, found the resident lying on his right side with several raised blister-like areas on the right hip and buttock and redness to the coccyx. She also observed soiled sheets, dried feces on both buttocks, a shirt with a dried yellow urine smell, and a large area of dried food on the back of the shirt. Witness statements from CNAs assigned to the hall that morning described dried feces on the resident’s bottom and back, stained sheets with feces and food, and dried food stuck to his clothing, noting that these wounds and soiling were not present at his last shower two days earlier. Interviews with CNAs on the day shift revealed that although they began work at 6:00 AM, they only entered the resident’s room to change him for the first time around 11:00 AM, stating they had previously only looked in on him and did not disturb him because he was asleep and had reportedly been changed before shift change. The Hospice Aide, arriving around 11:00 AM to provide a shower, reported that the resident was still wearing the same shirt from his prior shower two days earlier, which was dirty with dried food, dried feces, and yellow stains. The DON and nursing staff acknowledged that the resident was found with dried urine and feces on his body and bedding and that the resident had not been turned or changed at routine intervals, despite his care plan requirement for incontinence care every two hours.
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