Failure to Provide Timely Incontinent Care per Care Plan
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis, hypertension, and COPD was assessed as cognitively intact but dependent on staff for mobility, toileting, and personal hygiene due to limited range of motion and incontinence. The resident's care plan required staff to check for dryness and provide personal care every two hours. On the day in question, the resident was observed participating in activities and then brought to the dining room for lunch without being returned to her room for incontinent care as specified in her care plan. Later, when the resident was transferred to bed after lunch, her pants were found to be soaking wet. Staff confirmed that the resident had not been changed or provided with incontinent care for over five hours, with the last care provided early that morning. Interviews with the DON and CNA supervisor confirmed that the resident should have been checked and provided with care every two hours, and that this did not occur as required.