Failure to Conduct RN Assessment After Reported Delay in Incontinent Care
Penalty
Summary
A resident with chronic osteomyelitis, a diaphragmatic hernia, and urinary incontinence reported waiting five hours for incontinent care after a bowel movement. The resident, who required assistance with transfers and perineal care, called for help multiple times over a five-hour period, but staff did not respond until much later. The incident was documented in a grievance report, and the resident was cognitively intact at the time. The baseline care plan and physician's orders indicated the resident's need for significant assistance with mobility and toileting. Despite the resident's report of delayed care, there was no evidence that an RN assessment was conducted to evaluate for potential injuries or complications resulting from the delay. The Director of Nursing Services (DNS) was not aware of the allegation, and the LPN on duty was not informed of the untimely care concern. Facility policy for assessment following a change of condition was requested but not provided. The failure to conduct an RN assessment after the reported delay in care constituted a lapse in meeting professional standards of quality.