Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care and assistance with activities of daily living (ADLs) for a resident with cognitive impairment and incontinence. According to the care plan, the resident required assistance with toileting and was to be checked every two hours. However, direct observation revealed that the resident was not offered or provided incontinence care for over four and a half hours while he remained in his wheelchair, despite multiple interactions with CNAs. The resident's brief was found to be soiled and saturated only after survey staff intervened and notified a registered nurse, prompting care to be provided. Documentation inconsistencies were also noted, as CNA task records indicated incontinence care was provided at a time when the resident was observed napping in the dining room. Staff interviews confirmed that the expectation was to provide incontinence care every two hours and to address refusals by re-approaching the resident within 15 to 20 minutes. Despite these policies, the resident did not receive timely care, and staff did not follow the established protocol for managing incontinence and refusals.