Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of urine and required extensive assistance with activities of daily living did not receive timely incontinence care. The resident's facility assessment indicated a need for assistance with toileting and transfers. On the morning in question, the resident's daughter arrived to find the resident still in bed, soaked with urine, and attempting to get out of bed. The room had a strong urine odor, and the daughter was upset that the resident had not been toileted. Interviews with staff revealed that the night shift CNA last offered toileting at 2:30 AM, which the resident refused, and did not check on the resident again before the end of the shift. The day shift CNA reported only peeking into the resident's room at intervals without checking if the resident was wet or offering toileting assistance. The resident was not checked or changed until the daughter arrived and found the resident in a soiled state. The care plan for the resident included interventions to keep the resident dry and prevent skin breakdown, but these were not followed as documented.