Failure to Implement Scheduled Incontinence and Skin Care per Care Plans
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plans for two residents requiring skin and wound care, resulting in prolonged periods without incontinence care and skin monitoring. One resident, an older adult with COPD, multiple pressure ulcers to the left and right hips, back, and sacral areas, and atrial fibrillation, had a care plan last reviewed on 2/13/26 that required incontinence care every two hours and as needed, and maintenance of clean, dry dressings for pressure ulcers. Another resident, an older adult with multiple sclerosis, a stage 4 sacral pressure ulcer, major depressive disorder, and paraplegia, had a care plan last reviewed on 2/2/26 that required keeping the skin clean and dry with checks and changes every two hours to prevent skin breakdown and wound infection. On 3/13/26, between 7:00 AM and 11:45 AM, staff did not perform the scheduled incontinence care or skin monitoring for these two residents, leaving them in soiled conditions for over four hours despite the documented care plan interventions. During an interview at 12:10 PM the same day, a CNA acknowledged awareness of the residents’ care needs and the care plan requirements but stated that she did not provide the required incontinence care because she was waiting for the wound team. This failure to carry out the specific check-and-change and hygiene interventions as written in the residents’ comprehensive care plans constituted noncompliance with implementing care according to the residents’ person-centered goals and clinical needs.
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