Failure to Provide Timely Incontinent Care for Cognitively Intact Resident
Penalty
Summary
A deficiency occurred when a resident who is always incontinent of bowel and bladder, and is cognitively intact, was not provided timely incontinent care as required by facility policy. The policy states that incontinent residents are to be checked and changed every two hours and as needed. On the morning in question, the resident reported having been left in a soiled brief for almost three hours, despite using the call light multiple times to request assistance. Staff members entered the room, acknowledged the request, but did not provide the necessary care or ensure that another aide responded promptly. Observations confirmed that the call light was turned off without care being provided, and staff continued with other tasks. Interviews with CNAs revealed that the assigned aide did not change the resident during morning rounds because the resident did not indicate a need at that time, and other aides, though aware of the resident's request, did not provide care themselves or ensure it was completed. The DON and Administrator both confirmed that the expectation is for incontinent care to be provided at least every two hours and as needed, and acknowledged that the care provided did not meet this standard. The resident's medical record indicates diagnoses including acute kidney failure, heart failure, and depression, and confirms total incontinence, further underscoring the need for regular and timely care.