Neglect of Incontinent, Non-Ambulatory Resident’s Skin and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, non-ambulatory, incontinent resident from neglect by not providing necessary incontinence care, repositioning, and monitoring throughout a day. The resident had severely impaired cognitive skills, non-Alzheimer’s dementia, depression, was dependent for ADLs, and had a history of a Stage I pressure ulcer with a pressure-relieving mattress in place. On the day in question, a CNA got the resident up around late morning and, with assistance from another CNA, transferred the resident to a wheelchair for lunch. The resident ate little and was typically given a nutritional shake. One CNA reported that another CNA did not know how to make the shake and asked a third CNA to prepare it; another CNA stated she periodically gave the shake throughout the day. The resident remained seated in the wheelchair at the end of the table after the noon meal and was not moved out of the wheelchair or laid down in the afternoon as was commonly done to protect the resident’s skin. According to staff interviews, the CNA primarily responsible for the resident that day did not check or change the resident’s brief, did not provide peri care, and did not transfer the resident to bed before the end of her shift, relying instead on the absence of odor as an indicator that care was not needed. Another staff member, who was functioning as a patient care tech and not yet allowed to provide direct care independently, reported that by the time evening staff arrived, the resident had not been checked or changed all day, and she observed a sore on the resident’s bottom that may have reopened after sitting in a wet brief. The evening CNA and this staff member then changed a wet brief and provided an oral nutritional supplement, and the condition was reported to the RN. The Social Services Director confirmed that the CNA had stated she did not check the resident because she did not smell anything, despite facility policies requiring a check-and-change strategy for severely cognitively impaired, incontinent residents and a pressure ulcer prevention program focused on minimizing moisture exposure and redistributing pressure.
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