Failure to Provide Timely Incontinence and Hygiene Care
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple psychiatric diagnoses was not provided timely incontinence care. During an observation, the resident was found in the dining room sitting in a wheelchair, leaning to one side, with a strong odor of urine and bowel movement. The resident's sweatpants were partially pulled down, and there was visible bowel movement on his right hand. Staff confirmed that the resident had last been checked and changed at 10:00 a.m., despite facility policy and care plans requiring checks and changes every two hours. At the time of observation, it had been over three hours since the last care was provided. Interviews with staff and a family member revealed that the resident was frequently found with dried bowel movement on his hands during mealtimes, and staff did not consistently clean his hands before meals. The resident's care plans indicated a need for assistance with all activities of daily living, including toileting and hygiene, and required staff to check and change the resident every two hours. Facility policy and CNA job descriptions also outlined the expectation for prompt and regular incontinence care, which was not followed in this instance.