Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with diagnoses of obesity, hemiplegia, and hemiparesis following a cerebral infarction, who was assessed as cognitively intact and always incontinent, did not receive timely incontinence care. On the day in question, the resident was observed with the call light on, reporting that she was wet and had not received incontinence care since 4:00am. The resident's bed sheets were visibly soiled with urine, and there was a strong odor of urine present. The resident expressed feeling bad about not being provided care. The assigned CNA confirmed that she had not provided incontinence care to the resident until late in her shift, citing the need for assistance and staff being busy as reasons for the delay. Both the CNA and another staff member observed that the resident's brief and bed sheets were saturated with urine. The DON stated that the facility did not have an incontinence policy but expected residents to be checked and changed every two hours or as needed.