Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
A dependent resident with diagnoses including kidney failure, ileostomy status, weakness, and a history of falls was observed lying in bed with a covered breakfast tray on her bedside table, unable to eat because she was waiting for wound care. The resident expressed a preference to get out of bed to eat and reported being told she would be assisted after wound care, which had not yet occurred. The resident also reported that her incontinence brief had been put on incorrectly during the night, resulting in her wetting the bed throughout the night and remaining in a soiled bed. Upon observation, a large wet spot was visible on the bed, although the resident's brief had been changed that morning and was dry at the time of observation. Certified nursing assistant (CNA) 1 acknowledged awareness of the soiled bed and stated she had changed the resident's brief but did not change the bed linens, as she intended to do so after the resident was assisted out of bed for wound care. Despite knowing the resident's condition, CNA 1 did not return to the room to provide further assistance and instead attended to another resident. The resident's care plan indicated a need for assistance with dressing, grooming, toileting, and transfers, and the Minimum Data Set assessment documented frequent incontinence and substantial assistance needs for activities of daily living.