Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with bowel and bladder incontinence, as evidenced by observations, interviews, and medical record reviews. One resident, who was always incontinent and dependent on staff for all activities of daily living, was not checked or repositioned for extended periods. Despite care plans indicating the need for regular incontinence checks and repositioning, there was no documentation of specific intervals for these checks. Staff interviews revealed a lack of awareness regarding the timing of previous incontinence care, and direct observation found the resident heavily soiled with urine, with soiling extending to linens and wound dressings. Another resident, also always incontinent and dependent on staff, was observed to have developed excoriation and a rash due to inadequate incontinence care. The resident reported that staff were not providing the required two-hour checks and repositioning, which was corroborated by staff interviews and observations. The resident was found with excoriated skin, a large amount of urine, and a small bowel movement present, as well as two soiled incontinence briefs. Staff admitted to not having checked or changed the resident since assuming care and were unaware of the last time incontinence care was provided. Facility policy required that incontinent residents receive appropriate treatment and services, including regular checks and care to prevent infections and restore continence as much as possible. However, the lack of adherence to these policies, as demonstrated by the failure to provide timely incontinence care and repositioning, resulted in residents remaining soiled for prolonged periods and developing skin issues.