Failure to Provide Timely Incontinence Care Results in Neglect
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents with severe cognitive impairment and total incontinence. For one resident with dementia, continuous observation over a four-hour and seventeen-minute period revealed that neither nursing nor CNA staff checked or performed incontinence care. When care was finally attempted, the resident was found with a saturated incontinence brief containing both urine and feces, some of which was dried on the skin. Staff interviews confirmed that incontinence care should be provided every two hours, and that failure to do so constitutes neglect. In the case of another resident with a history of stroke and severe cognitive impairment, a similar period of observation showed that no incontinence care was provided by staff. When a CNA attempted to offer care, the resident refused, but the CNA acknowledged that care should still be offered every two hours regardless of refusals. Staff interviews reiterated the expectation for two-hour checks and identified lack of such care as neglect. Both incidents were brought to the attention of facility administration, including the administrator, director of nursing, and regional administrator. No additional information or corrective actions were provided prior to the survey exit.