Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
Staff failed to provide appropriate incontinent care for a resident with Alzheimer's disease, chronic kidney disease, and benign prostatic hyperplasia, who was dependent on staff for activities of daily living. The resident's care plan required frequent checks, assistance with toileting, and peri-care after each incontinent episode. Despite these directives, the resident was observed seated in a Broda chair near the nurses' station for an extended period, during which time a visible puddle of urine formed under the chair and the resident's clothing and chair became saturated with urine. Multiple staff members, including a registered nurse, certified medication tech, and nurse aides, passed by or interacted with the resident but did not check or change the resident or address the incontinence, even after the presence of urine was apparent. The resident remained in the same location for over two hours without being checked or changed, despite the facility's policy and staff statements that residents should be checked every two hours and as needed. It was only after the surveyor intervened and requested the resident be checked that staff provided incontinent care, changed the resident's clothing, and cleaned the chair. Interviews with staff revealed uncertainty about when the resident was last checked or changed, with some staff citing a busy workload and others indicating that the resident had been in the Broda chair since before their shift began. Staff acknowledged that the resident should have been checked and changed sooner, and that the presence of a puddle should have prompted immediate action. The deficiency was due to staff inaction and failure to follow the care plan and facility policy regarding incontinent care.