Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for activities of daily living, specifically toileting and personal hygiene. One resident, with diagnoses including lumbar radiculopathy, neuropathy, morbid obesity, and osteoarthritis, was documented as cognitively intact but fully dependent on staff for toileting. This resident reported that a CNA refused to change them until after lunch, regardless of need, and that this practice occurred on multiple occasions. The resident also described an incident where they had to wait until the next shift to be changed after requesting assistance at night. Staff interviews confirmed that some CNAs limited incontinence care to three times per shift, regardless of the resident's needs, and that delays in care often resulted in the resident being left in soiled linens and clothing for extended periods. Another resident, also cognitively intact and with diagnoses including morbid obesity and diabetes, reported similar issues with delayed incontinence care. This resident stated that some CNAs would respond to call lights but not return for hours to provide needed care. The care plans for both residents required staff to anticipate and meet needs, keep call lights within reach, and respond promptly to requests for assistance. Facility policies also required incontinence care to be provided after each episode and for residents to be checked approximately every two hours. Interviews with nursing staff and review of facility policies confirmed that the expectation was for residents to be changed and cleaned as needed, without arbitrary limits. However, staff practices did not align with these expectations, as some CNAs admitted to only performing incontinence care a set number of times per shift, regardless of the residents' actual needs. This resulted in residents experiencing discomfort and being left in soiled conditions, contrary to facility policy and care plan requirements.