F0677

G

Failure to Provide Timely Incontinence and ADL Care Resulting in Poor Hygiene and Skin Issues

Trinity, Texas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary ADL assistance and timely incontinence care to a dependent resident, resulting in poor personal hygiene and skin issues. The resident was an older adult with type 2 diabetes, colostomy, hemiplegia of the right dominant side, an indwelling Foley catheter, and an ostomy, and was care planned as dependent on staff for toileting hygiene and at risk for skin integrity problems. His care plans directed staff to keep his skin clean and dry, provide incontinence care as quickly as possible after voiding or bowel movements, ensure he was clean, dry, and free from odor, and maintain his dignity and privacy.

On the survey date, two CNAs entered the resident’s room to provide incontinence care and noted a strong urine odor. The resident was in bed on an air mattress, with contractures in both hands and long, dirty fingernails with a dark brown substance underneath. When linens were pulled back, a urine-soaked pillowcase with a strong odor was found between his thighs, and his groin and inner thighs were wet with redness noted to the mid-thigh. The underpad was wet with urine and had a brown ring extending to his upper back, and his back was entirely wet from urine. White, dried, flaky skin was observed around the base of his penis, and an old healed sacral wound with a small open area was noted. The CNAs cleaned his genital area and catheter tubing and placed a clean underpad, and both stated he would receive a shower.

One CNA stated that the resident’s condition appeared as if he had not been changed during the previous night, noting the bad urine odor and that his entire bed was wet. She reported that residents were to be checked every two hours and that she had last showered him two days earlier, at which time he had no redness or open areas on his buttocks. The other CNA, on her fourth day at the facility, stated that the resident looked very raw with a bad rash down his legs and that the brown rings on the wet underpad indicated he had been in that condition for a long time; she confirmed that rounds were supposed to be done every two hours and that earlier in her shift she had only emptied his catheter drainage bag without providing incontinence care. The resident reported that staff had come into his room a couple of times the previous night when his catheter began leaking and had placed something between his legs, that this was the first time anyone had come in that morning, that he could tell when he was wet, and that he did not like having dirty nails. The DON and Administrator both stated that residents should be checked at least every two hours, that walking rounds should be done at shift change to ensure residents are clean and dry, and that nails should be cleaned when visibly soiled, and acknowledged that being left wet would be unacceptable and could lead to skin breakdown, infections, or mental anguish.