Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care to a resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and unsteadiness, required substantial assistance with activities of daily living such as toileting and personal hygiene. Observations revealed that during a nearly four-hour period, staff entered the resident's room but did not check for incontinence or offer toileting assistance. On another day, the resident was moved between various activities and meals without being checked for incontinence or offered toileting assistance for over five hours. When finally checked, the resident was found soiled with urine and a bowel movement. Review of the care plan indicated the resident required supervision and cueing with ADLs, including prompt incontinence care and routine skin checks. However, staff did not follow these interventions, as evidenced by the lack of timely checks and care. Staff interviews confirmed that the resident should have been checked every two hours, but this protocol was not followed, resulting in prolonged periods without necessary incontinence care.