Failure to Provide Required Perineal Cleansing During Incontinent Care
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple health conditions, including multiple sclerosis and vascular dementia, did not receive timely incontinence care, resulting in wet clothing and a saturated brief. The CNA responsible had not attended to the resident for several hours due to other duties, and the facility's policy lacked specific guidelines for care frequency. The DON confirmed that care should be provided every two hours.
The facility failed to assess and treat urinary incontinence for a resident with multiple health issues, lacking a comprehensive bladder assessment and care plan. Another resident had an indwelling urinary catheter without documented justification, with no known reason for its use confirmed by staff and representatives.
A facility failed to provide proper incontinence care for a resident with Alzheimer's and dementia. The care plan required cleansing the perineum after each episode, but a CNA did not follow the correct procedure, particularly in cleaning the uncircumcised penis. The CNA admitted to being trained differently at the facility, which led to the deficiency.
The facility failed to provide proper indwelling catheter care for two residents, with one lacking adequate indication for catheter use and another missing documentation of catheter output. An LPN noted a diagnosis without supporting documentation, and the facility lacked a policy on catheter use reasons. The Administrator confirmed missing output records, violating the facility's urinary catheter care policy.
A resident with severe cognitive impairment and dependency on staff for personal hygiene received inadequate incontinence care. The CNA used two wet washcloths without a barrier, soap, or wash basin, and did not follow proper hand washing and glove use procedures. The facility's policy for incontinence care, which includes using a mild cleanser and applying a protective barrier ointment, was not adhered to during the care provided.
A facility failed to provide necessary incontinence care for a cognitively impaired resident with a history of cerebral infarction and dementia. The resident, who was always incontinent, was found with a soiled brief and saturated bedding, indicating a lack of timely care. Interviews revealed the resident was particular about who provided her care, and effective interventions were not in place to manage her preferences. The facility did not provide evidence of care being refused or performed by night shift staff.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, which was identified during a review of medical records, observations, staff interviews, and policy reviews. The resident, who was admitted with diagnoses including multiple sclerosis, vascular dementia, and hemiplegia, was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting and personal hygiene. The plan of care indicated that staff should change the resident per protocol, preference, and as needed. On a specific observation, the resident was found with wet pants and a saturated incontinence brief with a strong urine odor, indicating a lack of timely care. The CNA responsible for the resident's care admitted to not providing incontinence care since early morning due to being busy with other tasks. The DON confirmed that incontinence care should be provided every two hours, but the facility's policy lacked specific guidelines for the frequency of incontinence care and checks. This deficiency was part of a complaint investigation.
Inadequate Assessment and Care for Urinary Incontinence and Catheter Use
Penalty
Summary
The facility failed to adequately assess and treat urinary incontinence for Resident #73, who was admitted with multiple diagnoses including osteomyelitis, endocarditis, diabetes, and pressure ulcers. Upon admission, the resident was noted to be incontinent of bladder and bowel, yet there was no comprehensive bladder assessment conducted to identify the type of incontinence. Additionally, there was no plan of care developed to address the resident's incontinence. The resident's records showed a significant number of incontinence episodes, and interviews with the Director of Nursing and Corporate RN confirmed the lack of assessment and care planning. For Resident #57, the facility failed to provide an adequate indication for the use of an indwelling urinary catheter. The resident, who had diagnoses including end-stage renal disease and diabetes, was readmitted with orders for a urinary catheter without documented justification. Medical records, including physician and nurse practitioner assessments, lacked evidence of a valid indication for the catheter's use. Observations during the survey confirmed the presence of the catheter, and interviews with the Director of Nursing and the resident's representative revealed no known reason for its use.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident diagnosed with Alzheimer's disease and dementia, who was frequently incontinent with his bladder and always incontinent with his bowel. The care plan for the resident required cleansing of the perineum after each incontinence episode. However, during an observation of incontinence care, a CNA did not follow the proper procedure for cleaning the resident, particularly in handling the uncircumcised penis. The CNA wiped the resident in a downward motion on both sides and brushed down the penis without retracting the foreskin to clean beneath it, as required by the facility's policy. The CNA admitted during an interview that she was trained differently at the facility compared to her aide training, which included cleaning the foreskin and scrotum. The facility's policy for perineal care of a male resident specifies using a washcloth with mild soap, cleaning the urethral meatus if a catheter is present, and washing the penis in a circular motion while retracting the foreskin for uncircumcised residents. The CNA's deviation from this policy contributed to the deficiency in providing proper incontinence care for the resident.
Deficiencies in Indwelling Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care for two residents, leading to deficiencies in accordance with physician orders and care plans. For one resident, there was a lack of adequate indication for the use of an indwelling urinary catheter. The resident was admitted with a Foley catheter, and the Licensed Practical Nurse (LPN) noted urinary retention with neurogenic bladder as the reason for the catheter. However, the Nurse Practitioner (NP) could not find documentation to support this diagnosis, and the diagnosis of neuromuscular dysfunction of the bladder was only added a month after admission. The Director of Nursing confirmed the absence of a facility policy on reasons to maintain a Foley catheter. For another resident, the facility failed to document the output from the Foley catheter as required by the care plan and physician's orders. The treatment records showed missing documentation of catheter output for specific shifts over several days. The Administrator verified the absence of documentation for these dates and times. The facility's policy on urinary catheter care required maintaining a record of the resident's daily output, which was not adhered to in this case.
Inadequate Incontinence Care Provided to Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was dependent on staff for toileting and personal hygiene. The resident, who was admitted with diagnoses including a displaced right femur fracture, diabetes mellitus, and unspecified dementia, was observed receiving incontinence care that did not adhere to the facility's policy. During the observation, a CNA used two wet washcloths without a barrier beneath them and without soap or a wash basin. The CNA washed the resident's perineal area and rectal area, where a bowel movement was present, using the same washcloths, and dried the resident with a towel. The CNA did not follow proper procedures for hand washing and glove use, as she only changed gloves once during the process. The facility's policy required the use of perineal wash or a mild cleanser, pat drying, and the application of a protective barrier ointment, which were not observed during the care provided. This deficiency was identified during a complaint investigation and affected one of four residents sampled for activities of daily living.
Inadequate Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care for Resident #11, who was cognitively impaired and dependent on staff for incontinence management. Resident #11 had a history of cerebral infarction, hemiplegia, aphasia, dementia, and muscle weakness, and was always incontinent of bowel and bladder. The care plan for Resident #11 required incontinence care after each episode, but observations revealed that the resident was found with a soiled brief and saturated bedding, indicating a lack of timely care. The resident's room had a strong foul urine odor, and the resident had moisture-associated skin damage (MASD) to the gluteal fold and bilateral buttocks, which was stable but not improving. Interviews with staff revealed that Resident #11 was particular about who provided her care, allowing only certain CNAs to assist her. CNA #290, who was assigned to Resident #11, had not provided incontinence care since the start of her shift, and there was no evidence that the resident had refused care during that time. The Director of Nursing stated that residents should be checked and changed every two hours, but the Assistant Director of Nursing confirmed that effective interventions were not in place to manage the resident's care preferences. The facility did not provide evidence of incontinence care being refused or performed by night shift staff prior to the morning shift.
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