Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency occurred when a dependent resident with severe cognitive impairment and quadriplegia did not receive timely incontinence care. The resident, who was fully dependent on staff for all activities of daily living, was left soiled after a Certified Nursing Assistant (CNA) failed to provide care as directed by the assigned nurse. The resident's care plan specifically required staff assistance with toileting and incontinence care due to the resident's medical conditions, including brain damage and muscle weakness. On the day of the incident, the nurse assigned to the resident instructed the CNA to perform a brief change and clean the resident, with additional instructions to notify the nurse once the task was completed. The CNA did not follow these directives and left the unit without informing the nurse or providing the required care. The resident's legal guardian arrived later and found the resident heavily soiled, with stool present on the resident's body, clothing, and medical equipment. The nurse confirmed that the care had not been provided and reported the incident to facility management. Documentation and interviews confirmed that this was not the first occurrence of the resident being left soiled, as noted by the legal guardian. The failure to provide timely incontinence care was substantiated by multiple sources, including the nurse, the legal guardian, and facility records. The incident was documented in a grievance form and a performance improvement form, both indicating that the CNA did not render care as instructed and failed to follow supervisor directives.