Failure to Provide Timely and Adequate Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide proper incontinence care to several residents who were dependent on staff for activities of daily living. During initial rounds, one resident was found in bed with a saturated incontinent brief and was unable to recall the last time they had been changed. The resident's medical record indicated frequent incontinence of bowel and bladder, and their care plan required regular incontinence checks and assistance. Another resident was observed with a saturated brief that had soaked through to their gown, and staff acknowledged that care was delayed as they were attending to other duties. Additional observations included two residents with visibly soiled briefs, one with urine and the other with both urine and feces. In both cases, staff confirmed the need for incontinence care but did not provide it immediately. One of these residents had their call light on for 20 minutes requesting assistance, but no staff responded during that time. Medical records for these residents documented diagnoses such as cerebral infarction, impaired mobility, and always being incontinent, with care plans specifying the need for routine and as-needed incontinence care to maintain skin integrity. Interviews with CNAs, LPNs, and the DON confirmed that facility policy and staff expectations were to provide incontinence care every two hours or as needed, and to respond promptly to call lights. Despite these policies, residents were found unclean and wet, and staff acknowledged that sometimes it took a while to reach all residents. Facility policy stated that incontinent residents should be maintained clean and dry, but this was not consistently achieved as evidenced by the surveyors' observations.