Failure to Provide Adequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide adequate incontinence and catheter care for two residents. One resident, admitted with a history of stroke and urgency incontinence, was identified as a candidate for scheduled toileting and was cognitively intact. Despite care plan interventions for scheduled toileting and peri care after incontinence episodes, there were multiple instances where the resident was found with dried feces on the body, including the groin, buttocks, and thighs. Staff interviews confirmed that the resident was not fully cleaned after incontinence episodes, and at times, the resident remained in a wheelchair all day without care unless they specifically requested assistance. Staff also reported challenges in cleaning the resident completely, with some instances of refusal, which were communicated to nursing staff as per protocol. Another resident, admitted with chronic venous hypertension and a catheter, had physician orders and care plans directing catheter care each shift. On one occasion, the resident was not provided with incontinence or catheter care during the night shift, resulting in the resident not being changed for nine hours and the catheter bag not being checked. Staff confirmed that the resident's call for assistance was not answered in a timely manner, and care was only provided on the following shift. The administrator acknowledged that the expected care was not provided as required.