Neglect in Providing Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, identified as Resident R1, who was admitted with a history of cerebral infarction, left side weakness, and aphasia. The resident was assessed as dependent on staff for all self-care activities, including toileting. The care plan indicated a risk for skin impairment due to the resident's hemiparesis, obesity, impaired mobility, and incontinence, requiring staff to keep the resident's skin dry. On April 20, 2025, the resident's family member reported that the resident was left in a bowel movement from 11:30 a.m. until the next shift at 4:00 p.m., despite requests for assistance made to the front desk. The facility's documentation system, used by nursing assistants to record care provided, showed no record of incontinence care for the resident during the first shift on the day in question. The Nursing Home Administrator confirmed the family member's account of the incident and attributed the lack of care to staffing shortages due to the Easter holiday. This incident was determined to be neglect, as the facility was aware of the resident's needs but failed to provide necessary care, potentially resulting in physical harm or emotional distress.
Plan Of Correction
No retroactive correction for this deficient practice. Current residents that are dependent for toileting were audited to ensure timely incontinence care is being provided and documented in the POC Task program. Current CNAs were re-educated on the abuse policy relating to neglect and incontinence care, providing timely incontinence care for dependent residents and completing documentation in the POC Task program. Random audits will be completed by Director of Nursing or designee weekly x 4 weeks and then monthly x 2 months to ensure timely incontinence care is provided and documented in the POC Task program. Results of audits will be reported in monthly QAPI Meetings for further recommendations.