Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of bladder and required extensive assistance for personal hygiene did not receive timely incontinence care. The resident, who had diagnoses including obesity, abdominal hernia, and a colostomy, was found by day shift CNAs to be soaked through to the mattress and very wet after calling for assistance multiple times during the night. The care plan for this resident specified the use of incontinence products and frequent checks at night, with the goal of keeping the resident clean, dry, and odor-free. Interviews with staff revealed that the night shift CNAs did not check on the resident as required. Each CNA believed the other was responsible for the resident's care during the last bed check, and both admitted to not checking on her that morning. The resident herself reported calling for assistance twice due to urinary incontinence, but no one responded until after the shift change. She also stated that she had never asked staff not to check on her at night, contrary to what one CNA claimed. The facility's policy on activities of daily living required that residents receive essential services to maintain personal hygiene, including timely incontinence care. The failure to provide this care was confirmed by staff interviews, the resident's account, and review of the care plan and facility policy. The incident was brought to the attention of the DON and the administrator, who acknowledged the lapse in monitoring and communication among staff.