Failure to Provide Timely Incontinent Care as Directed by Care Plans
Penalty
Summary
The facility failed to provide incontinent care as documented in the care plans for two residents who were dependent on staff for personal hygiene and were incontinent of bowel and/or bladder. One resident, with neuromuscular dysfunction of the bladder and hemiplegia, was identified as always incontinent of bowel and dependent on staff for care. Documentation showed that on a specific day, there was no record of incontinent care being provided during the 7AM-3PM shift, despite care plans directing care every two hours. The resident was later found with soiled linens and evidence of inadequate care. Another resident, diagnosed with benign prostatic hyperplasia and also dependent on staff for personal hygiene, was always incontinent of urine and frequently incontinent of bowel. The care plan required incontinent care every two hours and as needed, but documentation for the 7AM-3PM shift was missing. This resident was also found with soaked pads, sheets, and briefs at the end of the shift. Staff interviews and facility documentation confirmed that the assigned nurse aide did not provide or document the required care during the shift in question.