Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with multiple diagnoses, including cerebral infarction, aphasia, dysphagia, pressure ulcer, hypertension, and anxiety disorder, was found to have not received timely incontinence care. During a head-to-toe skin check, the resident was observed with a saturated undergarment, stool present up through the vaginal area, and reddened buttocks, with no barrier cream noted. The resident had requested butt cream prior to the assessment. The assigned CNA reported that the last incontinence care provided was between 08:00 and 08:30 AM, and although the resident was seen at 10:00 AM to pick up a meal tray, no incontinence care was given at that time. Facility staff, including the DON and wound nurse, confirmed that the resident is incontinent, cognitively impaired, and completely dependent on staff for incontinence care, requiring visual checks every two hours. The resident's care plan and physician orders specify the use of barrier cream and regular changing of disposable briefs. Facility policy also requires appropriate care for residents unable to perform ADLs independently, with special attention to those with cognitive impairment. Despite these protocols, the resident was left in soiled conditions for an extended period, contrary to the established care plan and facility policy.