Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including impaired cognition, mobility impairment, and incontinence of bowel and bladder, did not receive timely incontinence care as required by their care plan and facility policy. The resident was dependent on staff for all activities of daily living and required incontinence checks every two hours. Documentation showed that after incontinence care was provided in the early morning, there was no further record of checks or care for several hours. Staff interviews confirmed that the resident was not checked for incontinence during shift changes, and the resident reported not receiving timely assistance. Direct observation revealed the resident remained in soiled briefs for an extended period, resulting in skin redness. Both CNAs involved acknowledged this was the first incontinence check since the start of their shift, despite the resident being known to require frequent checks due to heavy incontinence. The facility's policy and the Director of Nursing confirmed the expectation for two-hourly checks, which was not met in this instance.