Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, malnutrition, and other significant diagnoses was found to have not received timely incontinence care. The resident required total to substantial staff assistance for activities of daily living and was always incontinent of urine and bowel, with a documented risk for skin breakdown. During an observation, a certified nurse aide responded to the resident's request to be changed and discovered that the resident's bed linens, incontinence brief, blue pad, bed sheet, bed alarm safety pad, and mattress were all saturated with urine. The resident expressed discomfort, stating she was cold and uncomfortable, and could not recall when she was last changed. The aide was unaware of the last time the resident was checked or changed and noted that the situation was inappropriate, attributing it to possible inexperience among newer staff. The resident's care plan required staff to check and change her incontinence products upon waking, before and after meals, before bed, during nighttime checks, per request, and as needed. The Director of Nurses confirmed that residents should be checked at least every two hours and that being left in urine is a dignity issue and increases the risk for skin breakdown and infection. The facility's policy also stated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene. Despite these protocols, the resident was left in a saturated state, indicating a failure to provide timely and adequate incontinence care.