Failure to Provide Timely Incontinent Care
Penalty
Summary
A resident with a history of left fibula fracture and type 2 diabetes with hyperglycemia, who was incontinent of bowel and bladder, was not provided timely assistance with incontinent care. During the first week of admission, the resident reported waiting an hour before her brief was changed after a bowel movement, resulting in significant discomfort. On another occasion, after requesting to be changed due to a soaking wet brief when breakfast was served, the resident was told by the CNA that the request would be addressed after meal trays were passed. The resident waited approximately an hour before her brief was changed, causing further discomfort. Interviews with staff confirmed that call lights should be answered within five minutes and that residents should be checked and changed prior to meals, especially those with incontinence. The facility's care plan for the resident indicated the need for check and change incontinence management and clean, dry clothes after incontinent episodes. Facility policy also required immediate response to call lights and emphasized residents' rights to dignity and comfort. Despite these policies, the resident's needs for timely incontinent care were not met.