Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for toileting and frequently incontinent of bowel and bladder was not provided timely incontinence care. The resident, who had diagnoses including COPD, chronic atrial fibrillation, and pancreatitis, was observed waiting in his wheelchair for over an hour to have his soiled brief changed. Staff informed the resident that he needed to wait until his roommate's wound care was completed, which was expected to take 15 minutes but ultimately took longer. During this time, the resident remained in a soiled brief, and there was a noticeable odor of bowel movement. When care was finally provided, the resident was found to be wet with urine that had soaked through his pants, and he had also had a bowel movement. Interviews with staff confirmed that the resident waited an hour to be changed due to the ongoing wound care for his roommate and staff breaks. The nurse manager acknowledged that an hour was too long for a resident to remain in a soiled brief and that the resident should have been changed before wound care began. The DON stated that residents should be changed as soon as possible or within a set timeframe to prevent skin breakdown, and that other staff, such as the nurse manager, could assist if nursing assistants or nurses were busy. Facility policy required assistance with activities of daily living, including toileting and hygiene, for residents unable to perform these tasks independently.