Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically incontinence care, for two residents who were unable to perform these tasks independently. One resident, with diagnoses including atherosclerosis, type 2 diabetes, and overactive bladder, was found to have not been changed since the previous night despite being frequently incontinent of urine and always incontinent of bowel. The resident reported asking for assistance in the morning, but no staff responded. The assigned CNA confirmed she had not checked or changed the resident since starting her shift and had not been informed of the need. Facility policy required incontinence care to be performed as needed and residents to be checked at least every two hours, but this was not followed. Another resident, dependent on staff for toileting hygiene due to Parkinson's disease and other conditions, was observed in a wet brief late in the morning, having last been changed around 5 A.M. The resident confirmed he had not been checked or changed since then. An LPN checked the resident's brief, found it wet, but did not change it, instead stating she would get the CNA to do so. The LPN later acknowledged she should have changed the resident at that time. Both residents had care plans indicating the need for regular assistance and checks for incontinence, which were not adhered to by staff.