Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and severe cognitive impairment, who was fully dependent on staff for all activities of daily living and always incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to clean and dry the resident after each incontinent episode and to observe for skin irritation and redness. However, according to a family member, the resident was sometimes only changed once per shift instead of the expected twice, and on one occasion was found wet with urine in both the incontinence brief and gown, indicating the brief had not been changed since the morning. Interviews with staff confirmed that leaving a resident in a wet brief can result in rashes, skin breakdown, and urinary tract infections. The Director of Nursing acknowledged that residents are to be changed at the beginning of the shift and as needed, and that failure to do so puts residents at risk. The facility's policy on bladder and bowel incontinence emphasized the importance of preventive measures for infection control, but the observed and reported practices did not align with these standards.