Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infections, hemiplegia, hemiparesis, and muscle weakness, who was dependent on staff for personal care and incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to check and provide incontinence care as needed, and staff interviews confirmed that residents should be checked and changed every two hours and as needed. However, observation and interviews revealed that the resident was only changed in the morning before being transferred to a wheelchair and was not checked or changed again until the evening. During the day, the resident remained in her wheelchair without being offered incontinence care, and staff confirmed that she was not checked or changed after the initial morning care. When incontinence care was finally provided in the evening, the resident's brief was found to be saturated, bulging, and foul-smelling, and her buttocks were red. The resident reported feeling sore and confirmed that this was the first time she had been changed since the morning.