Failure to Provide Adequate Incontinence and UTI Prevention Care
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bladder and had a recent history of urinary tract infection (UTI) was not provided with adequate incontinence care. The resident, who was dependent on staff for all aspects of toilet hygiene and had moderately impaired cognition, was observed with a soaked incontinent brief at 10:35 AM, despite having last been changed at approximately 7:45 AM. The certified nursing assistant (CNA) responsible stated she planned to check and change the resident again at 11:30 AM, and admitted to relying on the resident's verbal report of being dry without physically checking. Documentation showed the resident was only assisted with toilet hygiene one or two shifts per day, with no specific frequency recorded per shift or day. Further review revealed that there was no care plan developed for the resident's UTI, despite a recent hospital treatment for the infection. The licensed vocational nurse (LVN) and the director of nursing (DON) confirmed that a comprehensive care plan should have been created upon the resident's readmission, but this was not done. Additionally, the facility lacked policies and procedures for incontinence care or UTI prevention. Staff interviews indicated that incontinence briefs should be checked every two hours, but this protocol was not followed, and there was no system in place to ensure consistent monitoring and intervention.