Failure to Provide Timely and Appropriate Incontinence Care
Penalty
Summary
The facility failed to provide appropriate incontinence care to two residents who required assistance with activities of daily living. One resident with diagnoses including cerebral palsy, intellectual disabilities, and schizoaffective disorder was documented as always incontinent and dependent for mobility and transfers. Despite care plan interventions to keep the resident clean and dry after each incontinent episode, the resident reported waiting at least 40 minutes for staff to respond to call lights and often remained in wet incontinence briefs and bedding for extended periods, especially at night. Direct observation confirmed that a CNA changed the resident's heavily wet brief without performing peri care before applying a new brief and dressing the resident. Another resident with a history of cerebral infarction, hemiplegia, and schizoaffective disorder was observed in public areas with saturated pants and a noticeable urine odor. The resident reported that staff response to requests for assistance was delayed, resulting in prolonged periods in wet clothing. The resident was later found in their room with wet clothing on the floor and attempting to use the bathroom independently without staff assistance. The facility's incontinence care policy requires care to keep residents dry, comfortable, and odor-free, but these standards were not met for the residents involved.