Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for incontinence care did not receive timely assistance. The resident, who had multiple diagnoses including spastic diplegic cerebral palsy, dementia, and intellectual disabilities, was documented as requiring total dependence for toileting and personal hygiene. The care plan specified the use of incontinence briefs, cleaning the peri-area with each episode, and regular checks during rounds. However, on the day in question, the assigned CNA was pulled to another floor at 3:00 P.M., leaving the resident without appropriate care. The resident was last changed before lunch at 12:20 P.M., and was observed sitting in the main lobby from 1:39 P.M. to 4:31 P.M. At 4:31 P.M., an LPN verified that the resident was moderately saturated with urine and was wet, and also noted an old scar area on the right upper buttocks. Staff interviews confirmed the absence of the CNA and the lapse in incontinence care. Facility policy on perineal care emphasized cleanliness, comfort, infection prevention, and regular observation of skin condition, but these standards were not met during the period when the resident was left unattended.