Failure to Provide Timely Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when a nurse aide (NA) failed to provide timely incontinence care to a resident who was dependent on staff for all activities of daily living due to Alzheimer's disease, vascular dementia, cerebrovascular accident, hemiparesis, and hemiplegia. The resident, who was always incontinent of bladder and bowel and required two staff for toileting, requested incontinence care prior to the NA going on break. The NA did not physically check the resident for incontinence at that time and did not provide care upon returning from break, citing instructions not to provide incontinence care during meal tray service. As a result, the resident remained in a soiled brief for approximately one hour, with a strong odor of bowel incontinence present in the room and hallway. When incontinence care was finally provided, the resident's brief was heavily soiled with bowel movement that had leaked onto her inner thighs and clothing. The resident reported being able to smell herself and stated this was not the first occurrence. Interviews with the NA, Director of Nursing, and Administrator confirmed that the resident's request for care was not addressed in a timely manner, and that the expectation was for incontinence care to be provided when requested, regardless of meal tray service schedules.