Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including traumatic subdural hemorrhage, muscle wasting, overactive bladder, and lack of coordination, did not receive required incontinence care. The resident was fully dependent on staff for toileting hygiene and was always incontinent of urine, as documented in the Minimum Data Set (MDS) and care plan. Physician orders and the care plan specified that incontinence care was to be provided at least every two hours and as needed, with a two-person assist, to maintain skin cleanliness and dryness. On the date in question, the resident did not receive incontinence care from 10:40 a.m. until 6:44 p.m., a period of approximately eight hours. Facility records and interviews confirmed that two CNAs failed to provide the required care during their respective shifts. The Director of Nursing verified that the resident should have received incontinence care at least every two hours, but this did not occur during the specified timeframe.