Failure to Provide Timely Incontinence Care
Penalty
Summary
Staff failed to provide timely incontinence care for a resident with multiple medical diagnoses, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. The resident was cognitively intact and required partial to moderate assistance for toileting, bed mobility, and transfers, and was frequently incontinent of bladder and always incontinent of bowel. According to the care plan, staff were to assist with cleansing and changing after each incontinence episode. Documentation showed the last check and change occurred at 2:54 A.M. From 9:32 A.M. to 11:26 A.M., no staff entered the resident's room to provide care. At 11:26 A.M., the resident was observed to be heavily soiled with urine, with a wet pad and noticeable odor. A CNA confirmed the resident had not been changed since 2:54 A.M. and acknowledged that care should have been provided every two hours. The resident also stated she would like to be changed every two hours, but this did not occur that morning. Facility policy required assistance with toileting and maintaining hygiene when residents could not do so independently.