Failure to Provide Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including incontinence care, did not receive appropriate care during an overnight shift. The resident had a history of severe cognitive impairment, was always incontinent of urine and bowel, and required total assistance with toileting hygiene. The resident's care plan specified the need for a toileting schedule and regular assistance due to cognitive loss and incontinence. On the shift in question, documentation for bladder continence and toilet use was missing from the CNA flowsheet. A CNA assigned to the resident confirmed during an interview that she did not provide incontinence care, stating she checked the back of the resident's incontinence brief and felt it was dry, so she did not change it. However, another staff member later found the resident in a fetal position with her gown tied in a knot and her incontinence brief soaked and very soiled.