Failure to Provide Timely Incontinence Care
Penalty
Summary
Staff failed to provide timely incontinence care for a resident with a history of type 2 diabetes mellitus, urinary tract infection, overactive bladder, and dementia. The resident was always incontinent of urine and bowel, wore briefs, and was not on a toileting program. Facility policy and the resident's care plan both required that incontinent residents be checked and provided perineal care at least every two hours. On the morning in question, the resident was not checked for incontinence or provided care until 10:40 AM, despite reporting to staff earlier that their bed was soaking wet and they had not yet been changed. Multiple staff interviews confirmed that the expectation was to check and change the resident every two hours, but on this occasion, the assigned aide had not provided any personal care due to being delayed by other duties. Observations revealed the resident's bed and mattress were saturated, and the resident had been waiting for care for several hours. The deficiency was substantiated through interviews, record reviews, and direct observation, confirming non-compliance with the facility's incontinence care policy.