Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and total dependence on staff for toileting hygiene was not provided incontinence care at least every two hours, as required by facility policy. The resident was documented as always incontinent and had a care plan indicating staff assistance with toileting throughout the day. On the day of observation, the resident was found sitting in a wheelchair with wet, soiled pants in the peri-area. The resident's roommate, who was alert and oriented, reported that incontinence care was last provided around 9:30am. The resident confirmed being changed in the morning but could not specify the time. The CNA assigned to the resident stated that incontinence care was provided at 10:00am and was scheduled again for 2:00pm, but acknowledged that sometimes the resident needed to be changed before the scheduled time. At 1:56pm, nearly four hours after the last reported care, the resident was still observed in the same wet condition. Facility policy requires incontinent residents to be checked and provided perineal and genital care every two hours, which was not followed in this instance.