Failure to Provide Timely Incontinence Care and Document Refusals
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with severely impaired cognition, dementia, and epilepsy, who was frequently incontinent of bladder and always incontinent of bowel. The resident's care plan required staff to check and change incontinence products every shift and as needed, maintain consistency in ADL routines, and re-approach the resident if care was refused, documenting each refusal. Despite these interventions, continuous observation revealed that the resident remained in urine-soaked sheets for an extended period, with a strong odor of urine present in the room, and staff did not offer toileting or change the resident's clothing or bedding during multiple interactions over several hours. Documentation in the facility's electronic health record indicated that the resident had only been toileted three times during the day in question, with no record of toileting or incontinence care for approximately eight hours. Staff interviews confirmed that the expectation was to offer toileting and check/change incontinence products every two hours, even if the resident refused, and to document each refusal. However, staff failed to follow these protocols, as evidenced by the lack of documented offers and the resident remaining in soiled conditions for an extended period. Family and staff interviews further corroborated that the resident would not have wanted to remain in urine-soaked clothing or bedding, and that staff were aware of the need to re-approach and document refusals. The facility's policy required necessary services for residents unable to perform ADLs, including maintaining personal hygiene. The observed failure to provide timely incontinence care and to document care refusals as required led to the identified deficiency.