Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
Surveyors determined that the facility failed to provide timely incontinence care to dependent residents on one nursing unit, as evidenced by direct observation, interviews, and record reviews. During an incontinence care tour, three residents were found in bed with saturated incontinence briefs; two of these residents also had soiled sheets. The residents involved had significant medical histories, including diabetes mellitus, dementia, and urinary tract infection, and all were documented as always incontinent of bowel and bladder, with care plans specifying the need for frequent incontinence care to prevent complications such as pressure ulcers. The care plans for these residents required incontinence care every two hours or every shift and as needed, but this was not provided as observed during the survey. Interviews with facility staff, including the LPN/Unit Manager and the Assistant Director of Nursing, revealed uncertainty regarding the facility's policy on incontinence care frequency, though both acknowledged that best practice would be care every two to three hours or at the end of the overnight shift. The CNAs responsible for the residents during the overnight shift were unavailable for interview. Review of the facility's Activities of Daily Living policy confirmed the expectation to monitor for incontinence and provide appropriate hygiene. The failure to provide timely incontinence care was confirmed by both observation and staff acknowledgment.