Failure to Provide Timely Incontinence Care After Fall
Penalty
Summary
The facility failed to ensure that staff checked for incontinence and provided incontinence care during routine rounds for a resident with severe cognitive impairment and a history of incontinence. After experiencing an assisted fall, the resident was placed in a geriatric chair and remained there overnight without being checked for incontinence or provided with incontinence care. Documentation and staff interviews confirmed that no toileting or incontinence care was provided from the time of the fall until the following morning, despite the resident's care plan and facility policy requiring checks every two hours. The resident involved had multiple medical conditions, including cauda equina syndrome, dementia, muscle weakness, and a history of falls, and was always incontinent of bowel and bladder. Staff interviews revealed that the resident was left in the day room in a geriatric chair after the fall and was not checked or changed during the night because staff did not want to wake the resident, even though the expectation was to provide care every two hours. The lack of incontinence care was corroborated by both nursing aides and an LPN, as well as by the absence of documentation for toileting or hygiene activities during the relevant shifts.