Failure to Provide Timely Incontinent Care to Dependent Resident
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide timely incontinent care to a resident who was dependent on staff for toileting hygiene and had impaired mobility and inability to alert staff. The resident, admitted with conversion disorder and aphonia, was care planned to be checked for bladder incontinence at least every two hours and as needed. Observations revealed that the resident was left in a wet gown and adult brief, with a noticeable smell of urine, and communicated through gestures and writing that care was not being provided as required. Interviews with CNAs indicated that the assigned staff did not check or change the resident's adult brief during their rounds, prioritizing other tasks and residents instead. CNA 7 admitted to planning to provide care to the resident at the end of rounds and did not check the resident for incontinence care, despite knowing the risks of not doing so. CNA 8 also delayed providing care, stating that other duties, such as showering other residents, took precedence even after being notified by an LVN that the resident needed to be changed. Facility policy required staff to provide appropriate care and services for residents unable to perform activities of daily living independently, including hygiene and toileting, in accordance with the care plan. Despite this, the resident was observed multiple times to be wet and not changed in a timely manner, and staff interviews confirmed that care was not provided as required by policy and the resident's care plan.