Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Parkinson's disease, dementia, and other significant diagnoses was not provided timely incontinence care. The resident, who was dependent on staff for all activities of daily living and at risk for pressure ulcers, was observed seated in a reclined wheelchair in the common area for over three hours without being checked for incontinence. Staff interviews confirmed that the resident was supposed to be checked every two hours, but it had been approximately 3.5 hours since the last check. Upon being transferred to bed, the resident was found to be heavily soiled with urine, which had soaked through the incontinence brief, clothing, and onto a blanket and shirt. Review of the resident's care plan and facility policies indicated that incontinence care was to be provided as needed, with frequent rounding and individualized interventions to maintain a clean and dry condition. However, the resident's profile did not specify a clear interval for incontinence checks, and staff relied on general instructions rather than specific timing. The failure to provide timely incontinence care resulted in the resident remaining soiled for an extended period, as confirmed by both observation and staff interviews.