Failure to Provide Timely Incontinent Care to Dependent Residents
Penalty
Summary
Three female residents with varying degrees of cognitive impairment, all dependent on staff for toileting hygiene, were not provided timely incontinent care as required by their care plans and facility policy. Observations revealed that these residents were found in their beds with intense urine and feces odors, and their briefs, pads, and linens were soaked and discolored from urine and feces. The care plans for these residents specified that perineal care should be provided after each incontinent episode and that residents should be checked at regular intervals, including upon rising, before and after meals, at bedtime, and as needed. A Certified Nursing Assistant (CNA) reported that she began her shift at 6:00 AM but had not had the opportunity to change some of her assigned residents, including the three affected individuals, by late morning. The Director of Nursing confirmed that incontinent care should be provided at least every two hours and that the environment should be odor-free. The facility's incontinence policy also requires periodic checks and perineal care after each episode, which was not followed in these cases.