Failure to Provide Adequate ADL, Incontinence, and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including incontinence and hygiene care, to residents who were dependent on staff. One resident with hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, and abnormal posture required substantial/maximal assistance with personal hygiene and was dependent on staff for toileting hygiene. This resident was found lying in bed on an incontinence pad with a large yellow wet area and a darker yellow ring, wearing two incontinence briefs that were completely saturated with urine and emitting a strong urine odor. When the CNA removed the briefs and provided incontinence care, the resident’s peri area and buttocks were reddened and excoriated, and the resident moaned and said “ouch” multiple times during cleansing. Despite a care plan directing staff to apply barrier cream after each incontinent episode for moisture-associated skin damage, no skin protectant was applied before a new brief was placed. Another resident, who was dependent on staff and used a reclining wheelchair and full-body mechanical lift, was observed sitting for hours in a reclined position that placed pressure directly on the coccyx, without engaging activity. When CNAs later transferred this resident to bed, the incontinent brief showed dark blue wetness indicator lines and was saturated with dark yellow urine, and the resident smelled of urine. Examination of the coccyx revealed a 1-centimeter open area with exposed granulation tissue, surrounding pallor, and mottled redness, with no dressing found in the bed or brief. A CNA stated that this resident is changed every two hours and is laid down after lunch, but also reported that the last incontinence change had occurred when the resident was gotten up at breakfast, indicating a gap of several hours without incontinence care. A third resident with hemiplegia, repeated falls, aphasia, and chronic kidney disease required substantial/maximal assistance with personal hygiene. This resident was observed with a splint on the left hand and long fingernails on the right hand, with a large amount of dark substance under the fingernails. When asked, the resident agreed to have the nails cleaned and cut. The care plan indicated the resident required assistance with daily care needs related to hemiplegia, and the facility’s nail care policy required removal of dirt from under fingernails and performance of nail care on shower days and as needed. The DON stated that residents’ hands should be washed before meals and that he would expect residents’ nails to be clean, but the resident’s observed nail condition showed that this assistance with hygiene had not been provided as required.
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