Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with a history of osteoporosis, urinary incontinence, hypertension, and dementia did not receive timely incontinence care. The resident, who was always incontinent of bladder and frequently incontinent of bowel, was dependent on staff for toileting. Documentation showed no record of incontinence care being provided from early morning until noon. Multiple observations throughout the morning revealed the resident remained in a common area in a wheelchair without being offered incontinence care, and by late morning, there were noticeable odors of urine and stool. Further investigation found the resident's clothing and wheelchair were wet with urine, and the incontinence brief was heavily saturated with urine and a small amount of stool. Staff interviews confirmed that incontinence care should be provided every two hours, but the assigned CNA was unaware of when the last care had been given due to lack of communication from the previous shift. The facility's policy required routine incontinence care, but this was not followed, resulting in the resident remaining in soiled conditions for an extended period.