Failure to Provide Timely Incontinence Care and Comprehensive Care Planning
Penalty
Summary
The facility failed to provide a comprehensive incontinence care plan and timely assistance with toileting for a resident with a history of mixed incontinence, orthopedic aftercare following hip replacement, pressure ulcer, and muscle weakness. The resident was identified as always incontinent of urine and bowel, requiring substantial to maximum assistance for lower body dressing and supervision or touching assistance for toilet transfers. Despite these needs, the resident's care plan did not include an incontinence care plan, and no bladder/bowel incontinence assessment was found in the medical record. Multiple observations revealed that the resident repeatedly activated the call light requesting assistance to be changed out of a wet pad and to get dressed, but staff responses were delayed. On one occasion, the resident waited over two hours before being assisted by an LPN, after initially being told by a nursing assistant that help would arrive soon. The resident expressed frustration about being left in a wet pad for extended periods and reported that this occurred almost daily, with staff often providing excuses or not entering the room promptly. Interviews with staff confirmed that the resident's requests for assistance were delayed due to staffing limitations, with only one nursing assistant assigned to the hallway at the time. The DON acknowledged that staff should enter the room when a call light is activated and that residents should not have to wait over an hour for toileting or dressing assistance, nor be left in a wet pad for two hours. The facility's own policy requires timely assessment and individualized management of incontinence, which was not followed in this case.