Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including toileting and personal hygiene, was not provided timely incontinence care. The resident, who had diagnoses including diabetes mellitus, seizures, hypertension, muscle weakness, and was always incontinent of urine, was observed crying in bed with a wet adult diaper. Both a Registered Nurse Supervisor and a Certified Nursing Assistant checked the resident and acknowledged the need for a diaper change but left the bedside without providing the necessary care. The Certified Nursing Assistant later stated she did not change the resident because she needed assistance, and confirmed that the resident should not have to wait for a diaper change. Interviews with staff confirmed that residents who are wet or soiled should be changed immediately to prevent complications such as skin irritation, yeast infections, and pressure ulcers. The facility's care plan for the resident specified that good skin care should be performed after each episode of incontinence. The facility's policy also required that residents receive care to maintain or improve their ability to carry out activities of daily living. Despite these requirements, the resident was left wet for approximately an hour, resulting in distress.