ASHLAND, KY - Federal inspectors documented severe assessment failures at Kingsbrook Lifecare Center that resulted in a resident requiring emergency penile surgery after staff failed to properly examine an uncircumcised male for months despite his repeated complaints of burning and pain.
Assessment Protocol Breakdown
The June 2024 inspection revealed that 73-year-old Resident 99, admitted in February with heart conditions and kidney disease, experienced months of ignored symptoms before staff discovered a severe penile infection. Despite having an intact mental status with a cognitive assessment score of 14 out of 15, the resident's repeated reports of burning during urination went uninvestigated.
Federal regulators found that facility staff failed to follow basic nursing protocols for uncircumcised males. The Kentucky Medicaid Nurse Aide Testing Manual clearly states that perineal care for uncircumcised men requires retracting the foreskin for cleaning and inspection, then returning it to its natural position.
The inspection revealed critical gaps in the resident's care plan. While staff documented general skin inspection requirements, no specific protocols addressed the specialized care needs for uncircumcised residents. The care plan included interventions for pressure ulcer prevention and incontinence management but lacked specific guidance for penile assessment and care.
Timeline of Medical Deterioration
The resident's condition progressively worsened from February through April 2024. Initial nursing assessments showed no skin problems, but by mid-March, documentation began noting redness in the groin area. By late March, staff recorded excoriation, yet no targeted intervention occurred.
Despite these documented skin changes, nursing assessments from April 7-10 made no mention of penile area problems. The resident had been transferred between units on April 10, potentially contributing to communication gaps about his condition.
On April 12, a nursing aide finally discovered the severe infection when she found abnormal drainage and called for nursing supervision. The supervising nurse found "an open wound to the top of his penis with a moderate amount of malodorous tan drainage."
Emergency Medical Intervention
The discovered wound required immediate medical attention. Hospital records documented balanoposthitis - inflammation of the foreskin and glans in uncircumcised males - along with significant infection. Bacterial cultures revealed Klebsiella oxytoca and Streptococcus intermedius, both serious pathogens requiring aggressive treatment.
Medical analysis shows these bacterial infections can develop when proper hygiene protocols are not maintained. Klebsiella oxytoca, commonly found in healthcare settings, demonstrates multiple drug resistance and can cause severe tissue damage. The combination with Streptococcus intermedius indicates a polymicrobial infection requiring immediate intervention.
On April 17, surgeons performed penile ulcer debridement and partial excision of the glans penis. The operative report documented a 3-centimeter area of necrotic tissue requiring removal. This surgical intervention represents the most severe outcome of untreated penile infection in nursing home settings.
Professional Standards Violations
Medical protocols clearly establish that comprehensive skin assessments must include examination of all body areas, particularly for high-risk residents. For uncircumcised males, standard nursing practice requires regular foreskin retraction during hygiene care and skin assessments to prevent accumulation of bacteria and debris.
The facility's own policies stated that comprehensive care plans should include "input from all disciplines" and describe services needed to maintain residents' "highest practicable physical, mental, and psychosocial well being." The failure to address specialized care for uncircumcised residents directly violated these standards.
Staff interviews revealed significant knowledge gaps. Multiple nursing aides reported receiving no specific training for uncircumcised male care, either in nursing school or facility orientation. One aide stated she only knew proper technique from caring for a family member.
Communication and Documentation Failures
The inspection revealed a concerning pattern of incomplete communication. The resident repeatedly reported burning sensations to staff on his original unit, but these complaints were not properly investigated or communicated during his transfer to another floor.
Nursing documentation showed staff treated symptoms with topical medications for presumed irritation, but failed to conduct thorough assessments that would have revealed the underlying infection. A urinalysis was performed but showed no urinary tract infection, leading staff to incorrectly assume the burning was related to skin irritation rather than penile infection.
Multiple staff members acknowledged the assessment should have been more thorough. The facility's medical director stated the incident led to extensive education about differences in care between circumcised and uncircumcised males, acknowledging the knowledge gap that contributed to the outcome.
Systemic Care Planning Deficiencies
The inspection documented that Kingsbrook's care planning system lacked mechanisms to identify and address specialized needs for uncircumcised residents. While the facility had protocols for general skin assessment, no specific interventions addressed penile hygiene requirements.
Staff interviews revealed that while assessment forms included options for documenting circumcision status, this information was not systematically incorporated into daily care routines or aide assignments. The MDS Coordinator confirmed that although custom interventions could be added for individual residents, this was not standard practice.
The quality manager stated that comprehensive skin assessments should examine "every nook and cranny," but the failure to implement this standard for the affected resident demonstrates a gap between policy and practice.
Medical Consequences and Recovery
The resident's infection required extended hospitalization and ongoing wound care after his return to the facility. The surgical debridement removed significant penile tissue, permanently altering the resident's anatomy. Hospital discharge notes indicated continued antibiotic requirements and specialized wound management.
Medical literature indicates that severe penile infections in elderly males can lead to permanent functional impairment, chronic pain, and psychological trauma. The resident's case required ongoing wound care nursing and represents a completely preventable medical emergency.
The family member interviewed by inspectors reported that emergency department staff described the condition as "total neglect" that "should never have happened." This assessment reflects the preventable nature of the medical crisis through proper nursing assessment protocols.
Regulatory Response and Corrective Actions
Federal inspectors cited Kingsbrook under two major regulatory standards: failure to develop comprehensive care plans addressing individual resident needs, and failure to provide appropriate treatment according to professional standards. Both violations were classified as causing actual harm to residents.
The facility's response included implementing enhanced education for nursing staff about specialized care requirements for uncircumcised males and revising assessment protocols to ensure comprehensive skin evaluation. These corrective measures acknowledge the systemic nature of the care failures.
This case demonstrates how seemingly minor oversights in nursing assessment protocols can escalate to serious medical emergencies requiring surgical intervention, highlighting the critical importance of comprehensive, individualized care planning in nursing home settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kingsbrook Lifecare Center from 2024-06-28 including all violations, facility responses, and corrective action plans.
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