Failure to Provide Complete Incontinent Care and Timely Checks
Penalty
Summary
The facility failed to provide appropriate care and services to two residents who were incontinent of bladder, resulting in both being left in urine-saturated briefs with a strong urine odor. Observations revealed that during incontinent care, staff did not adequately clean the residents' pelvic and groin areas, only washing the buttocks and backs of the legs before applying a clean brief. This incomplete hygiene practice was observed for both residents, despite their care plans indicating a need for extensive assistance with activities of daily living, including toileting and hygiene. Resident #4 had a history of cerebral infarction, hemiplegia, hemiparesis, and vascular dementia, with moderate cognitive impairment and dependence for toileting hygiene. Resident #5 had diagnoses including Parkinsonism, ataxia, spinal stenosis, and hemiplegia, also with moderate cognitive impairment and dependence for toileting hygiene. Both residents were observed to be left in urine-saturated briefs prior to care, and the care provided did not include cleaning of the front and peri areas as required. Interviews with residents indicated delays in being checked or changed, with some residents reporting being left wet for extended periods and staff not returning after call lights were activated. Staff interviews confirmed that all soiled areas should be cleaned during incontinent care, and the DON stated that residents should be checked every two hours if incontinent. However, the facility lacked a specific policy on the timing of incontinence checks, and the observed care did not meet the expected standards for thorough cleaning.