Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL), specifically incontinence care, for three dependent residents. For one resident with diagnoses including unspecified psychosis, Meniere's disease, and osteoarthritis, the care plan required cleaning the peri-area with each incontinence episode. However, on the day of observation, the resident had not been cleaned up for the day and was found with a completely saturated incontinence brief after having breakfast in bed. Another resident with dementia, Alzheimer's disease, and major depressive disorder, who required substantial staff assistance for toileting and hygiene, was also not cleaned up for the day. This resident was found with a saturated incontinence brief, a damp incontinence pad with a dark urine circle, and a strong urine odor in the room, with liquid noted on the bathroom floor. The resident did not refuse care or display aggressive behaviors during assistance. A third resident, diagnosed with epilepsy, muscle weakness, cognitive communication deficit, and mixed incontinence, was observed lying in bed with a saturated incontinence brief. Staff confirmed that incontinence care had not yet been performed for this resident. Interviews with CNAs and the Director of Nursing indicated that incontinence care should be provided at least every two hours or more, in accordance with the facility's protocol. Despite this, the observed residents had not received timely incontinence care, resulting in saturated briefs and unaddressed hygiene needs.