Failure to Provide Timely Incontinence Care for Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents who were both severely cognitively impaired and always incontinent, as documented in their most recent MDS assessments. For one resident with dementia, continuous observation over a period of more than four hours revealed that no nurse or CNA checked or provided incontinence care. When care was eventually attempted, the resident was found with a saturated incontinence brief containing both urine and feces, some of which was dried on the skin. The process of providing care was further complicated by improper transfer techniques and lack of effective communication between CNAs. For the second resident, who had a history of stroke and was also severely cognitively impaired and always incontinent, a similar period of observation showed no incontinence care was provided. The assigned CNA confirmed that care should be offered every two hours and acknowledged not being informed about the resident's care status from the previous shift. When care was offered, the resident refused, and the CNA stated that refusals were frequent but that care should still be offered regularly. Interviews with CNAs revealed a lack of communication during shift changes regarding which residents had received incontinence care. Both CNAs acknowledged the importance of regular incontinence checks and the potential for skin breakdown if residents are left wet or soiled for extended periods, but neither had received adequate handoff information from the previous shift. The findings were communicated to facility administration, with no additional information provided prior to survey exit.