Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically incontinence care and toileting, for two residents who required substantial staff support. One resident, who was incontinent of urine and stool and required significant help with personal hygiene and toileting, was observed with a call light on for over two hours while requesting to be changed due to being soaked in urine. Despite repeated requests and staff acknowledgment of the need, the resident was not provided incontinence care until nearly ten hours after the last change, resulting in saturated bedding and a wet mattress. Another resident, cognitively impaired due to dementia and also requiring substantial assistance for hygiene and toileting, remained in a wheelchair in a common area for several hours without being toileted or changed. Staff were unable to confirm when incontinence care was last provided, and the assigned CNA reported not having had time to attend to the resident since the start of the shift. Facility policy requires incontinence care at least every two hours, but this standard was not met for either resident.