Failure to Provide Timely Denture and Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, non-Alzheimer's dementia, depression, visual and hearing loss, and dependence on staff for personal care did not receive proper denture and incontinence care. The resident's care plan required staff to encourage and assist with denture use and to provide regular incontinence checks and changes. However, the resident's dentures were found by a complainant in a cup on a discolored paper towel, covered in what appeared to be white mold, and not in the resident's mouth as required. Staff were unable to locate the dentures in the resident's room and later found them in the Staff Development Coordinator's office, with no explanation for their placement there. Observations revealed that the resident was left sitting in a wheelchair and later in a recliner for extended periods without incontinence checks or changes. Staff did not interact with the resident during these periods, and no incontinence care was provided between 10:15 a.m. and 4:15 p.m., despite the facility's policy of checks every two hours. When finally checked, the resident was found to be wet with urine, and both the resident's clothing and recliner were soiled. Staff admitted that documentation only occurred when a resident was changed, not when checked and found dry, leading to uncertainty about the timing of care provided. The facility's own policies and the resident's care plan required regular assistance with oral hygiene and incontinence care, but these were not followed. The Director of Nursing confirmed that the observed lapse in incontinence care was unacceptable and acknowledged the poor condition of the dentures as shown in photographs. The deficiency was substantiated by direct observation, staff interviews, and review of care plans and facility policies.