Failure to Assess and Report Incontinence-Related Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, specifically related to skin assessment and incontinence care. The resident was an adult male with pneumonia, type 2 diabetes, and a right above-knee amputation, who was always incontinent of bowel and bladder and required extensive assistance with ADLs. His MDS and care plans documented bladder incontinence and potential for altered skin integrity, with interventions including incontinent care after each episode, weekly skin inspections, keeping skin clean and dry, and notifying appropriate staff of any new skin breakdown. At the time of survey, there were no documented active ulcers, wounds, or skin problems for this resident. During interview, the resident reported frequently waiting 30 minutes to an hour for incontinent care, stated he was currently wet and had not been changed that day, and described pain and itching around his genitals. He reported that staff often answered his call light and said they would return but did not come back. Observation of incontinent care by CNAs showed appropriate technique during that episode, but the resident’s scrotum was reddened and open wounds were visible on his right thigh/groin area. The charge nurse initially stated the resident had no active skin integrity issues and that no new concerns had been reported, and the treatment nurse also reported being unaware of any open wounds or active wound care orders for this resident. Further interviews revealed that a CNA had observed redness to the resident’s genitals and surrounding skin for about a week but did not report it to nursing staff, instead applying barrier cream on her own because the redness “comes and goes.” This was contrary to facility expectations and prior in-service education that CNAs immediately report any skin integrity concerns, including redness and rashes, to nursing staff. When the treatment nurse subsequently assessed the resident, she identified open wounds on the right inner thigh and redness to the scrotum, and a skin assessment documented new in-house moisture-associated skin damage/incontinence-associated dermatitis measuring 10 cm by 10 cm. Facility policies and in-service materials required perineal care to prevent infection and skin irritation and to observe skin condition, and directed staff to notify the wound care nurse immediately for new wounds, rashes, redness, or any abnormal skin finding, which did not occur in this case.
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