Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who is incontinent of urine and dependent on staff for activities of daily living, including toileting and hygiene, was found lying in bed with a strong, foul odor present in the room. Upon observation, the resident's brief, pad, and sheet were saturated with dark, foul-smelling urine, with the saturation reaching through to the mattress. Certified Nursing Assistants (CNAs) present at the time of observation stated they had not changed or assisted in changing the resident earlier that day and were unaware of when the resident was last changed. The CNA assigned to the resident reported that the last change occurred at approximately 7:30 AM, despite facility policy and the Director of Nursing stating that incontinent residents are to be changed every two hours and as frequently as needed. The resident's care plan confirms total dependence on staff for toileting and hygiene, and the facility's incontinence care policy requires residents to be kept dry, comfortable, and odor-free.