Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident, who required assistance with activities of daily living (ADLs) including toileting, bathing, and dressing, did not receive timely incontinence care. During a morning observation, the resident was found sitting in a wheelchair with his shirt raised, exposing his abdomen, incontinence brief, and back. There was a wet red stain on the shirt, and scrambled eggs were present on his shorts and lower abdomen. Later that day, when the resident was returned to his room for incontinence care, staff discovered the brief was heavily soiled with urine and bowel movement, and dried scrambled eggs were still present near the pubic area. The CNA confirmed that although the resident had been showered and changed before breakfast, he had not been changed again until the afternoon, despite being aware of the soiling. The resident's medical record indicated multiple diagnoses, including stroke with left side hemiplegia, Parkinson's disease, and cognitive impairment, necessitating substantial to maximum assistance with ADLs. The care plan required staff to check and change the resident as needed for incontinence. Documentation showed inconsistent recording of incontinence care, and the facility's policy required routine assistance with incontinence care, including brief and clothing changes. The DON acknowledged that incontinence care should have been provided more promptly.