Neglect of Incontinence Care Resulting in Incontinence-Associated Dermatitis
Penalty
Summary
The facility failed to ensure a resident’s right to be free from neglect when an assigned nurse aide did not provide necessary incontinence care, resulting in superficial incontinence-associated dermatitis. Facility policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The resident had diagnoses including major depressive disorder, congestive heart failure, and hypertension, and a comprehensive care plan identifying risk for skin breakdown and pressure injury related to incontinence and mobility deficits, with an intervention for assistance with AM/PM care and reporting abnormal skin observations. On the day of the incident, the resident reported to an aide at some point before noon that she had experienced a bowel movement and needed to be changed. The aide reportedly told the resident she would inform the assigned aide, and then left the room after the resident turned off the call light. Later, at the start of the evening shift, another nurse aide responded to the resident’s call bell and found the resident incontinent of urine and feces. The resident stated she had not been changed since the morning. An RN assessment at that time noted the bed was soaked from side to side, the brief was saturated and dripping, diarrhea was caked from the upper groin to both thighs, and the bilateral buttocks were bright red. The resident also stated she was fearful of retaliation from the aide she believed would think she had reported her. Review of the nurse aide assignment sheet showed that the resident was assigned to a specific nurse aide on day shift, although that aide later stated she did not provide any care to the resident because she believed the resident was not on her assignment. The NHA indicated that nurse aide assignments are created by licensed nursing staff and that aides are responsible for reviewing and understanding their assignments prior to the start of their shift. Review of nurse aide task documentation for that day showed no recorded incontinence care for the resident on day shift. Subsequent nursing documentation described reddened, non-blanchable skin to the buttocks and gluteal fold, with the resident reporting mild pain, and later notes described intact skin with blanching redness and moisture trapped in the peri area with redness, consistent with superficial incontinence-associated dermatitis.
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