Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide resident-directed care and treatment consistent with the comprehensive plan of care for a resident diagnosed with benign prostatic hyperplasia, dementia, and anxiety disorder. The resident's care plan included an intervention to check the resident approximately every two hours and provide incontinence care as needed. However, documentation revealed that the resident was last assisted with toileting at 9:19 AM, and by 11:47 AM, the resident was observed sitting in a dining area with a puddle of urine underneath his chair. Despite the observation, the resident remained in the dining area until 1:09 PM, when two nurse aides wheeled him into a shower room for incontinence care. The Director of Nursing confirmed that the resident was incontinent and that a nurse aide had been informed of the need for a change but got sidetracked with other tasks. The lack of timely incontinence care was only addressed after the surveyor's inquiry, highlighting a failure to adhere to the resident's care plan and facility policy.
Plan Of Correction
1. Resident 1 did not have any adverse reactions. 2. The residents in North Dining room will be monitored by the LPN's to ensure that the residents are being checked q 2 hours for incontinent care. 3. Nursing staff will be educated on the expectation that residents are checked and changed q 2 hours by the DON/Designee on 1/6/2025. 4. DON/Designee will QA weekly for 4 weeks, then monthly to ensure that residents are checked and changed q 2 hours. Results will be reviewed with QAPI committee. 5. Compliance by 1/21/2025.