Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
A resident with multiple diagnoses, including an above-knee amputation, chronic ulcers, and a stage 3 sacral pressure ulcer, was dependent on staff for activities of daily living (ADL) and incontinence care. The resident's care plan required staff to check and change incontinence briefs every two hours and as needed. Observations and interviews revealed that the resident often had to wait up to 30 minutes for assistance after a bowel movement and was found in bed with soiled linens, a strong urine odor, and heavily stained bedding. Staff assigned to the resident's care stated they were occupied with other duties and had not yet attended to the resident, despite being expected to complete incontinence care within the first two hours of their shift. The facility's policies required timely and thorough incontinence care and morning rounds to ensure residents' needs were met. Documentation from the nurse practitioner indicated the resident had incontinence-associated dermatitis, attributed to prolonged moisture exposure from incontinence episodes. The failure to provide timely incontinence care and maintain cleanliness of the resident's environment was directly observed and confirmed through staff interviews, highlighting a lapse in adherence to the resident's care plan and facility policies.