Failure to Provide Timely and Properly Assisted Incontinence Care with Incomplete Documentation
Penalty
Summary
The facility failed to provide timely incontinence care, ensure the appropriate number of staff assisted with care, and document care for a resident with hemiplegia, reduced mobility, and incontinence. Interviews and record reviews revealed that the resident, who was cognitively intact, reported extended periods—sometimes up to 8-12 hours—without a brief change, depending on the staff on duty. Staff interviews confirmed that the resident required two-person assistance for bed mobility and brief changes, as documented in the care plan and resident profile, but at times only one staff member provided care. Documentation of brief changes was inconsistent, with significant gaps between recorded changes on multiple dates. The care plan specified a two-person assist for bed mobility and incontinence care, and the resident was always incontinent of bowel and bladder. Despite this, staff sometimes performed changes alone, and documentation did not reflect the frequency of care required. The DON acknowledged that if care was not documented, it was considered not done, and agreed that the resident should always have two-person assistance for these tasks. Facility policy required necessary services for residents unable to perform ADLs, including elimination and hygiene, but these were not consistently provided or recorded for this resident.