Failure to Provide Timely Incontinent Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinent care and assistance with activities of daily living (ADLs) for a resident who was totally dependent on staff. Observation revealed that the resident's brief was very saturated with a dark yellow substance and there was a strong urine odor in the room. The resident, who was cognitively intact and had diagnoses including multiple sclerosis and urinary incontinence, reported that bed checks were not performed every two hours and that they were typically changed only once a day. Staff interview confirmed that the resident had not been changed between 6:45 a.m. and a bit after 10:00 a.m., and that the facility policy required changing residents every two hours. The CNA stated they were unable to follow the policy due to being too busy. These findings demonstrate that the facility did not adhere to its own policy for regular incontinent care, resulting in the resident remaining in a saturated brief for an extended period.