Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for toileting due to incontinence of bowel and bladder, did not receive timely incontinence care as required by her care plan and facility policy. The resident, with a history of congestive heart failure, diabetes mellitus, and chronic kidney disease, reported that her last incontinence care was provided at approximately 5:00 A.M. and that she had not been checked or changed since then. Staff interviews confirmed that the resident had not received incontinence care during the morning shift, despite the facility's policy to check and change incontinent residents every two hours and as needed. Observation later in the morning revealed the resident was wearing a heavily saturated incontinence brief, and staff present at the time verified the resident's report and the condition of the brief. Multiple CNAs interviewed acknowledged that they had not provided incontinence care to the resident during their shifts, with one CNA noting a staffing shortage due to a call-off. Review of the facility's Activities of Daily Living policy confirmed the expectation for necessary services to maintain personal hygiene for residents unable to perform ADLs.