Failure to Provide Timely Incontinence Care Upon Resident Request
Penalty
Summary
A resident with osteomyelitis and bowel and bladder incontinence, who was cognitively intact and dependent on staff for all activities of daily living, was not provided timely incontinence care upon request. The resident required a mechanical lift for transfers and was frequently incontinent, as documented in the care plan. On the morning of the survey, a strong odor of feces was noted coming from the resident's room. The resident reported having requested to be changed before daylight, but staff did not respond to his request in a timely manner. When incontinence care was finally provided, the resident was found with a saturated brief containing a large amount of soft stool, and the bottom sheet was soiled. The resident's skin was pink and intact, and the stool was not dried or stuck to the skin. Nurse aides interviewed stated that the resident was often left in this condition by the previous shift and that they were instructed not to perform patient care while breakfast trays were being distributed. The resident confirmed that he had asked the night shift aide for assistance, who acknowledged the request but did not return. The resident remained in a soiled brief until after breakfast trays were passed by the day shift. The Director of Nursing confirmed that residents should be clean and dry before the first shift and that it was unacceptable for residents to remain in soiled briefs for extended periods.