Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to provide timely and appropriate interventions to prevent urinary incontinence for a resident with multiple medical conditions, including severe cognitive impairment, irritable bowel syndrome, and impaired mobility. Despite care plans indicating the need for two-hour incontinence checks and maximum assistance with toileting, documentation showed a lack of consistent checks and assistance. Staff interviews revealed that both the LPN and CNA assigned to the resident were unaware of the last incontinence check and had not observed the resident since assuming care. Observations confirmed the resident was left unattended, resulting in incontinence episodes that were not contained by the adult brief, leading to soiling of clothing, bedding, and the mattress. Medical record reviews and staff interviews indicated that the resident's daughter often had to assist with changes and cleaning, as staff did not consistently provide the required support. The facility's incontinence policy required appropriate treatment and services based on comprehensive assessment, but the resident did not receive the necessary care to prevent incontinence episodes. The deficiency was identified through observation, record review, and interviews, confirming non-compliance with the facility's own policies and care plans.