Failure to Provide Timely Incontinent Care and Brief Changes
Penalty
Summary
Surveyors identified that staff failed to provide incontinent care and pressure injury prevention for one resident over an approximately three-day period. The resident had complete paraplegia, intact cognition, and was dependent on staff for toileting, lower body dressing, transfers, and most ADLs, with a care plan directing that disposable briefs be changed every two hours and as needed, and that the perineal area be cleaned after each incontinence episode. On one early morning, CNA 1 provided incontinent care, applied a clean brief, and wrote his initials, time, and date on the brief because he was concerned that staff were not changing this resident as required. CNA 1 was then off duty for several days. When CNA 1 returned to work, he observed that the resident was still wearing the same incontinent brief he had applied days earlier, with the same date and time markings, indicating that the brief had not been changed during that period. Interviews with the DON and DSD confirmed their awareness that the resident had been left soiled and in the same brief for about three days, despite the resident’s history of refusal of ADLs. Facility policies on ADLs and fecal incontinence required that residents be provided hygiene and toileting services in accordance with assessed needs and that residents be cleaned after each episode of incontinence, with refusals reported to a supervisor. The failure to follow the care plan and policies resulted in the resident remaining in the same incontinent brief for days, which the DON stated placed the resident at increased risk for skin breakdown and affected his dignity.
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