Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for activities of daily living, specifically incontinence care. Both residents had severe cognitive impairment and were always incontinent of bladder and bowel, as documented in their care plans and Minimum Data Set (MDS) assessments. The care plans for both residents specified that they were not candidates for a toileting program and required staff to provide toileting hygiene as needed for incontinent episodes, with the goal of keeping them clean and dry. Observations revealed that both residents remained in their Broda chairs in the dining room for extended periods without being checked for incontinence. For one resident, there was a gap of three hours between incontinence checks, during which the resident was found to have had a thick and sticky bowel movement. The assigned CNA reported relying on smell to detect bowel incontinence and only visually checked the front of the brief for urine incontinence, without fully inspecting for fecal incontinence. The other resident was also not checked for incontinence for over three hours, with the CNA confirming that she did not open the brief to check for urine or bowel incontinence, again relying on smell for detection of fecal incontinence. Interviews with the CNA, the unit manager RN, and the DON confirmed that the expectation was for residents to be checked for incontinence at least every two hours and that a visual check for both urinary and bowel incontinence was required. The facility's policy also required staff to provide incontinence care as needed. Despite these expectations and policies, staff did not perform timely or thorough incontinence checks for the two residents, resulting in a failure to meet their care needs as outlined in their care plans.