Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs), specifically toileting and incontinence care, for two residents who were unable to perform these tasks independently. For one resident with severe cognitive impairment and total dependence on staff for ADLs, observations revealed that she was not offered or provided with incontinence care or toileting assistance for a period of four hours. Staff interviews confirmed that the resident was last changed at 7:45 a.m., and no further care was provided until a hospice aide arrived for a scheduled shower, at which point the resident was found soiled with urine and had a reddened area near her tailbone. The care plan for this resident required assistance with toileting throughout the day and always upon rising, but this was not followed during the observed period. Another resident, who had moderate cognitive impairment and required staff assistance for all ADLs, was also not provided with timely incontinence care. Observations showed that the resident was not checked or changed from 5:03 a.m. until 10:40 a.m., a period of over five hours. During this time, staff did not offer toileting or incontinence care before or after breakfast, and the resident was found to be wet and soiled when finally changed. Interviews with staff indicated that care was delayed due to workload and assumptions that the resident would use the call light if assistance was needed. However, the resident was unable to effectively use the call light due to physical limitations, and there was no documentation of her refusing care. Both residents had care plans and facility policies in place that required regular assessment and assistance with toileting and incontinence care, but these were not consistently implemented. Staff interviews revealed inconsistent practices and reliance on subjective judgment rather than adherence to scheduled care routines. The lack of timely incontinence care resulted in residents remaining soiled for extended periods, contrary to their care plans and facility policy.