St. Pauls Health Care: Neglect Causes Penis Injury - CA
The overnight aide at St. Pauls Health Care Center told investigators this was his "routine practice" with residents he considered heavy wetters. He acknowledged using the same technique at other facilities.
The incident came to light on August 3 when a day-shift nursing assistant discovered the resident during routine morning care. The CNA found the man wearing two diapers — one placed correctly, and a second with a hole cut through the middle. The resident's penis protruded through the opening, which was so tight it acted like a rubber band around the organ.
Licensed nurse LN 1 examined the resident after being notified of the concerning diaper placement. The nurse observed visible swelling and discoloration of the penis, along with skin breakdown where the modified diaper was restricting blood flow. The opening was constricting the tip of the penis so severely that it caused obvious physical harm.
The resident appeared embarrassed during the examination and was guarded when staff tried to assess his condition. He reported pain from the constriction and initially seemed reluctant to discuss who had placed the diapers in that manner.
The day-shift CNA who discovered the situation said the resident appeared upset with her for reporting the incident to the charge nurse. The resident's embarrassment was evident throughout the morning as staff worked to address the immediate medical concerns.
During the facility's investigation, the overnight registry aide admitted responsibility for the double-diaper technique. He told investigators he routinely applied two diapers in this manner for residents with heavy incontinence, viewing it as a practical solution rather than recognizing it as harmful.
The nurse administrator who conducted the internal investigation confirmed the registry aide was responsible for the neglectful care. She emphasized that double-diaper placement should never occur because it significantly increases the risk of skin breakdown and other complications.
Facility policy explicitly prohibits double-diaper placement, and all certified nursing assistants are expected to demonstrate competency in proper incontinence care before working with residents. However, the nurse administrator discovered no documentation verifying that the registry aide had completed required competencies before beginning work at the facility.
The administrator acknowledged that the resident experienced both physical and psychological harm from the incident. Beyond the visible injury and reported pain, the resident suffered embarrassment and distress from the inappropriate care and subsequent examination.
The facility's five-day summary report, dated August 7, documented the full scope of the investigation. Administrators interviewed the registry aide on August 5, two days after the incident was discovered. During that interview, he readily admitted to the double-diaper technique and explained his rationale for using it.
The investigation concluded that the aide's actions constituted substantiated neglect based on his deviation from standard care practices. The technique resulted in physical harm to the resident and violated regulatory standards, resident rights, and facility protocols.
According to the facility's own analysis, the deviation from accepted practices posed significant risks to both resident safety and dignity. The constricting diaper caused immediate physical injury while also subjecting the resident to unnecessary embarrassment and psychological distress.
The nurse administrator stated the facility could not guarantee resident safety when staff failed to meet basic standards of care. The incident highlighted vulnerabilities in the facility's oversight of registry staff and competency verification processes.
Registry agencies provide temporary staffing to nursing homes, often during overnight shifts when regular staff may be unavailable. These workers are expected to maintain the same care standards as permanent employees, but facilities may have less direct oversight of their training and competencies.
The facility's abuse and neglect policy, approved in March 2025, defines neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy specifically identifies failure to provide proper incontinence care as an example of potential neglect.
Federal regulations require nursing homes to ensure all staff, including temporary workers from registry agencies, demonstrate competency in their assigned duties before providing resident care. Facilities must verify that registry staff can safely perform required tasks and understand proper care techniques.
The improper diaper application violated multiple aspects of quality care standards. Beyond the immediate physical injury, the technique demonstrated a fundamental misunderstanding of safe incontinence management practices and resident dignity requirements.
Proper incontinence care involves using appropriately sized products, ensuring correct placement, and monitoring for skin integrity issues. Modifying incontinence products by cutting holes or using multiple layers can create serious health risks including circulation problems, skin breakdown, and infection.
The resident's guarded behavior during examination suggested he understood something was wrong with his care but may have felt powerless to address it directly. His embarrassment reflected the psychological impact that inappropriate care can have on nursing home residents.
The facility's investigation process followed required protocols for suspected abuse or neglect cases. Staff promptly reported the incident, conducted interviews with involved parties, and documented their findings in the required five-day summary report.
However, the incident raised questions about the facility's screening and oversight of registry staff. The lack of documented competency verification for the aide who caused the injury suggested gaps in the facility's quality assurance processes.
The registry aide's admission that he used this technique at other facilities indicated the problem might extend beyond St. Pauls Health Care Center. His casual description of the practice as routine suggested he viewed it as acceptable care rather than recognizing the potential for harm.
The resident's experience illustrates how seemingly small deviations from proper care protocols can result in significant physical and emotional harm. What the aide described as a practical solution for managing incontinence became a source of injury, pain, and humiliation for a vulnerable resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Pauls Health Care Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ST. PAULS HEALTH CARE CENTER in SAN DIEGO, CA was cited for neglect violations during a health inspection on September 4, 2025.
Pauls Health Care Center told investigators this was his "routine practice" with residents he considered heavy wetters.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.