Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on assistance for activities of daily living (ADLs) did not receive adequate incontinence care in accordance with the facility's policy. The resident, who had significant medical conditions including anemia, gastrostomy, tracheostomy, and toxic encephalopathy, was noted to be severely cognitively impaired and fully dependent on staff for personal care tasks such as toileting hygiene and dressing. Observations and interviews revealed that the resident was routinely changed only twice per shift, despite the facility's policy requiring incontinence pad or brief changes every 2 to 4 hours or as needed to keep the resident clean and dry. Multiple observations confirmed that the resident was frequently found with a brief full of urine, and both the gown and bed linens were wet with urine at the time of care. Staff interviews corroborated that this was a recurring issue, with the resident's brief and linens consistently wet during scheduled changes. The Director of Nursing acknowledged that the resident required more frequent changes than were being provided to maintain skin integrity and cleanliness, as outlined in the facility's continence management and perineal care policies.