Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Facility staff failed to provide timely assistance with activities of daily living (ADLs) and incontinence care for one resident who was unable to perform these tasks independently. The resident, who had a history of sepsis, obstructive and reflux uropathy, and anemia, was cognitively intact but required substantial to maximal assistance with toileting hygiene, bathing, and personal hygiene due to muscle weakness and other medical conditions. The resident's care plan specified the need for assistance with toileting and incontinence care after episodes of incontinence. On the day in question, the resident was observed wearing a wet incontinent brief with pink-colored urine and a foul smell that had not been changed from 7 a.m. to 3:10 p.m. The resident confirmed that the last change and cleaning occurred around 7 a.m. and sometimes had to remind staff for care. Staff interviews revealed a lack of communication between CNAs during shift change, resulting in the resident being left in soiled conditions for several hours. Facility policy required that residents unable to perform ADLs independently receive necessary assistance to maintain hygiene and grooming, which was not followed in this instance.