Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bowel and bladder did not receive timely incontinence care. The resident reported being left wet and soiled for approximately 11 hours, from 4:00 AM to 3:00 PM, without being changed or repositioned. The resident stated that unless they used the call light, staff on the midnight shift did not check or reposition them, and if not changed during that shift, they had to wait until after breakfast. The resident described multiple unsuccessful attempts to have their brief changed, including using the call light several times and informing various staff members, but did not receive assistance until the evening shift began. Review of the clinical record showed the resident was dependent for toileting, had no bowel or bladder program, and was care planned for incontinence care per facility policy, with instructions to keep the resident clean and dry. Documentation for the day in question was incomplete, with no records of incontinence care provided during the day shift. The resident's complaints were corroborated by their email to the DON, which detailed the lack of response to call lights and the extended period without care, resulting in urine-soaked bed linens. Interviews with staff revealed confusion regarding room assignments, with the CNA assigned to the resident unaware of the assignment until the end of the shift. The DON confirmed that the standard of care was to check for incontinence every two hours, but there was no documentation of refusals or care provided on the day in question. The facility's policy required incontinence care as needed based on resident request or regular checks, but this was not followed, leading to the resident remaining soiled for an extended period.