Failure to Provide Timely Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide timely and appropriate incontinence care for four residents who were sampled. Multiple residents reported that staff did not respond promptly to call lights, especially during night shifts, resulting in residents remaining in soiled briefs for extended periods, sometimes until the next shift. In some cases, staff turned off call lights without providing care, and residents had to wait for significant periods, sometimes up to an hour and a half, before receiving assistance. These incidents were corroborated by resident interviews and review of care documentation, which showed missed incontinence care tasks across various shifts. The residents involved had significant medical histories and functional limitations. One resident had diagnoses including overactive bladder, muscle weakness, and required substantial assistance with toileting hygiene, being always incontinent for bowel and bladder. Another resident, with a history of femur fracture and diabetes, also required assistance and was always incontinent, but reported that staff response was slow, leading to prolonged periods in soiled briefs. A third resident, with severe cognitive impairment and hemiplegia, was dependent on staff for all toileting needs and was not a candidate for a toileting program, yet did not receive incontinence care as scheduled. A fourth resident, with a history of fracture and muscle atrophy, was occasionally incontinent and dependent on staff, but also experienced significant delays in care. Care plans for these residents specified the need for regular incontinence checks and care, including checking and changing upon arising, before and after meals, at bedtime, and as needed. Staff interviews revealed that CNAs relied on residents to use call lights to request care and checked on residents when time permitted, rather than following scheduled checks. The Director of Nursing acknowledged previous issues with night shift care and stated that residents should be checked every two hours, with documentation required for each shift. However, documentation and resident reports indicated that these protocols were not consistently followed, resulting in unmet care needs.