Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency was identified regarding the failure to provide timely incontinence care to a dependent resident who lacked capacity. Documentation and staff statements revealed that the resident was not assisted with toileting, cleaning, or changing absorbent pads or briefs in a timely manner. On the morning in question, staff discovered the resident in bed with sheets and clothing soaked with urine, and a brown ring was observed on the sheets. Multiple nursing assistants confirmed that the resident was found in this condition during morning rounds, requiring a full bed bath and linen change. The record review indicated that the resident was dependent and unable to care for themselves. Despite a report from the night shift aide stating the resident had been changed and bathed, subsequent staff found the resident in a soiled state. The incident was initially reported as an allegation of neglect, and statements from several nursing assistants corroborated the observation that the resident had not received timely incontinence care.