Failure to Provide Timely Incontinence Care and Maintain Cleanliness
Penalty
Summary
Staff failed to provide timely and appropriate incontinence care for a resident who was severely cognitively impaired and dependent on staff for care. During an observation, a CNA removed the resident's brief, which was heavily soiled with amber-colored urine and emitted a strong odor. The resident's wheelchair and pants were also soaked in urine. Interviews with the CNAs revealed that the resident had not been checked or changed for over four and a half hours, despite facility policy and staff expectations to provide peri-care every two hours. One CNA admitted she had not checked the resident as required because she was busy, and both CNAs confirmed the extent of soiling. The Director of Nursing confirmed that residents should be checked and changed every two hours, or more frequently if they are heavier wetters, to maintain cleanliness and prevent infection. The resident's medical record indicated diagnoses including acute kidney failure and mild intellectual disabilities, and the most recent assessment showed severe cognitive impairment. The failure to provide timely incontinence care and maintain cleanliness placed the resident at risk for skin breakdown and urinary tract infection, as acknowledged by staff during interviews.