Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were frequently incontinent and dependent on staff for assistance. One resident, admitted with kidney failure and muscle weakness, was cognitively intact and required help with toileting. Documentation showed inconsistent recording of incontinence care, with some shifts lacking documentation and no refusals noted. The resident reported that it was easier to wear a brief than wait for staff, and described an incident where they soaked through their wheelchair, leaving urine on the floor, due to not receiving timely assistance. Staff interviews confirmed that the resident remained in a soiled state between lunch and dinner without incontinence care, and staff acknowledged being busy and not providing care as scheduled. Another resident, admitted with benign prostatic hyperplasia and lower urinary symptoms, was also cognitively intact and required staff assistance for incontinence care. Documentation indicated inconsistent care and no refusals. A grievance was filed after the resident requested a brief change and did not receive assistance for an hour, resulting in the resident being soaked and urine present on the floor. Staff interviews corroborated the delay in care and the resident's complaint. Facility policy required staff to check on residents every two hours and offer assistance, but this was not consistently followed for these residents.