Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A resident with a history of stroke, left-sided hemiplegia, dysphagia, epilepsy, diabetes, and severe cognitive impairment was admitted with total dependence for activities of daily living and was always incontinent of bowel and bladder. The care plan and physician's orders required incontinence care and repositioning every two hours to maintain skin integrity and assist with wound healing. On the date in question, documentation and interviews revealed that the resident was not provided incontinence care or repositioned as required between 4:00 PM and 7:00 PM. The resident's family member discovered the resident saturated with urine at 7:00 PM, and facility records failed to show incontinence care provided between 12:21 PM and 10:19 PM that day. Staff interviews confirmed that the resident was checked at 4:00 PM and not again until the family member raised concerns at 7:00 PM. The nurse aide responsible did not return to the resident's room after the initial check, and the nurse confirmed the resident was wet when assessed. Facility policy and the Director of Nursing Services both indicated that incontinent residents unable to request care should be checked and changed every two hours, which was not done in this instance. The lack of timely incontinence care and repositioning was not in accordance with the resident's care plan and facility policy.