Failure to Provide Timely and Consistent Incontinence Care
Penalty
Summary
Multiple residents experienced significant delays and omissions in receiving incontinence care, as evidenced by both resident interviews and documentation reviews. One resident reported that after activating her call light at night, a staff member entered, turned off the light, and left without providing care, resulting in her remaining in a wet brief until the next shift. This resident stated that such incidents occurred three to four nights per week, and that staff did not check on her during the night as care plans required. Documentation for this resident showed missing entries for incontinence care across several shifts, indicating a lack of consistent care and documentation. Another resident, who was always incontinent for bladder and bowel, reported that staff response to her requests for incontinence care was slow, often resulting in her waiting over forty-five minutes after urinating before being assisted. This was described as a daily occurrence. Documentation for this resident also revealed missing entries for incontinence care on multiple shifts. Additional residents described similar issues, including long wait times for call lights to be answered, especially during night shifts, and having to remain in soiled briefs for extended periods. One resident reported waiting up to an hour and a half for care, with staff sometimes turning off call lights without providing assistance. Staff interviews corroborated these findings, with CNAs reporting being assigned to care for large numbers of residents alone, making it difficult to provide timely incontinence care. Staff also indicated that care was sometimes left undone between shifts due to heavy workloads and insufficient staffing. The DON acknowledged ongoing struggles with staffing and confirmed that documentation of incontinence care was often incomplete, despite facility policies requiring residents to be checked every two hours and care to be documented on each shift.